Name :    ______________________________________________________________________

Address :    ____________________________________________________________________

                    ____________________________________________________________________

                    ____________________________________________________________________

Tel. No. :    _______________________________       Fax :    ____________________________

Organisation :    _________________________________________________________________

Designation :    __________________________________________________________________

Address :    ____________________________________________________________________

                    ____________________________________________________________________

                    ____________________________________________________________________

Tel. No. :    _______________________________       Fax :    ____________________________

Email :    ________________________________      URL :    _____________________________

Date of Birth :    ______________________     Place Of Birth :    __________________________

Membership of Other Organisations :    ______________________________________________

 _____________________________________________________________________________

 _____________________________________________________________________________

 _____________________________________________________________________________

Name of Spouse :    _____________________________________________________________

We are sending herewith the Membership donation by cash / cheque / draft for Rs.    _________

_________________________________  drawn in the name of _________________________ .

Kindly send future communications to my residence / office address given above.

____________________

             Signature