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PRAYAAS®

MEMBERSHIP FORM

MEMBERSHIP NO.  _______________________  (For Official Use Only)

NAME ____________________   __________________   ________________________

(FIRST NAME )                           (MIDDLE NAME )                               (LAST NAME)

PLACE OF BIRTH                             __________________________    BLOOD GROUP _____

DATE OF BIRTH                                ____/____/_______                          M/D/V __________

( dd / mm / yyyy)                                (Member/ Donor/ Volunteer)

GENDER(M/ F)  _____      OCCUPATION   ____________________________

OFFICIAL ADDRESS        _________________________________

_________________________________

_________________________________  PIN : _________

OFFICIAL PHONE                            ______________________ Extension _______________

E-MAIL ADDRESS                            _____________________________________________

RESIDENCE ADDRESS    _________________________________

_________________________________

_________________________________  PIN : _________

RESIDENCE TEL. NO.      ______________________

PROFESSIONAL QUALIFICATIONS

SL NO. NAME OF INSTITUTION NAME OF DEGREE/COURSE DURATION DISTINCTIONS
1.
2.
3.

EXTRACURRICULAR /SOCIAL WORK/ORGANISATIONAL EXPERIENCE

SL. NO. NAME OF ACTIVITY/ORGANISATION DURATION POST HELD ANY OTHER DETAIL
1.
2.
3.
4.

NATIVE PLACE/ADDRESS_________________________________

_________________________________

_________________________________  PIN : _________

AREA OF SKILLS                              1.______________________________________________

(Technical/ Non-technical)                2.______________________________________________

3.______________________________________________

ANY OTHER INFORMATION WHICH WILL BE helpful to us

________________________________________________________________________________________________________________________________________________________________________________________________________________________

How would you like to receive the magazine : E-mail/ Web Page/ Post

DAY(S) IN A WEEK (When you can commit yourself) :  __________________

CONTRIBUTION PER MONTH :   Rs._________ /-                  FROM : ____/_________

(mm/yyyy)

INTRODUCED BY :  Mr./Ms. ____________________________________________

SIGNATURE

_______________________

PLACE                  _______________________                          DATE       ____/____/_______

( dd / mm / yyyy)