ZONAL MEMBERSHIP FORM - होम - विप्र...
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ZONAL MEMBERSHIP FORM (RAJASTHAN) Zonal Office : Plot No. 8, Jadaun Nagar – B, Opp: Durgapura Railway Station, Jaipur-302018 (Rajasthan) (Under clause 3(A), 3(B) and 3(C) of the regulation of Vipra Foundation) PLEASE FILL IN CAPITAL LETTERS WITH BLACK INK Date: ___/__/____ Name : Date of Birth Father’s / Husband’s Name : DD MM YYYY Residential Address : Marriage Anniversary DD MM YYYY Native Place & District Contact No. : Mobile: Office / Work Address : Sub-Caste Contact No. : Gotra Mobile: Occupation( ) Email ID : Fax: Service Business Profession Others (Specify) District : Chapter: I wish to be amember as follows: 100/- General Member 250/-Active Member 1000/- Super Active Member 11000/- Zonal Life Member Enclosed Cheque/ Cash No.: Dated Drawn on (Rupees I agree with rules and Regulation of Vipra Foundation and shall devote my time, skill to do all the best for Vipra Foundation Place: Date: Signature of Applicant: FOR OFFICE USE ONLY Receipt No.: Date: Amount: ( Rupees MEMBERSHIP ENROLLED: 100/- General Member 250/-Active Member 1000/- Super Active Member 11000/- Zonal Life Member Membership No. : GM/ AM/ SAM/ ZLM/ Office Bearer's Signature:
Transcript of ZONAL MEMBERSHIP FORM - होम - विप्र...
ZONAL MEMBERSHIP FORM
(RAJASTHAN)
Zonal Office :
Plot No. 8, Jadaun Nagar – B, Opp: Durgapura Railway Station, Jaipur-302018
(Rajasthan)
(Under clause 3(A), 3(B) and 3(C) of the regulation of Vipra Foundation)
PLEASE FILL IN CAPITAL LETTERS WITH BLACK INK Date: ___/__/____
Name : Date of Birth
Father’s / Husband’s Name : DD MM YYYY
Residential Address : Marriage Anniversary
DD MM YYYY
Native Place &
District
Contact No. : Mobile:
Office / Work Address : Sub-Caste
Contact No. :
Gotra
Mobile: Occupation( )
Email ID : Fax:
Service
Business
Profession
Others (Specify)
District : Chapter:
I wish to be amember as follows:
100/- General Member 250/-Active Member 1000/- Super Active Member 11000/- Zonal Life Member
Enclosed Cheque/ Cash No.: Dated Drawn on
(Rupees
I agree with rules and Regulation of Vipra Foundation and shall devote my time, skill to do all the best for Vipra Foundation
Place: Date: Signature of Applicant:
FOR OFFICE USE ONLY
Receipt No.: Date: Amount: ( Rupees
MEMBERSHIP ENROLLED:
100/- General Member 250/-Active Member 1000/- Super Active Member 11000/- Zonal Life Member
Membership No. : GM/ AM/ SAM/ ZLM/
Office Bearer's Signature:
ZONAL MEMBERSHIP FORM
(DELHI) Zonal Office :
B-33, Flatted Factory Complex, Jhandewalan, New Delhi-110055
(Under clause 3(A), 3(B) and 3(C) of the regulation of Vipra Foundation)
PLEASE FILL IN CAPITAL LETTERS WITH BLACK INK Date: ___/__/____
Name : Date of Birth
Father’s / Husband’s Name : DD MM YYYY
Residential Address : Marriage Anniversary
DD MM YYYY
Native Place &
District
Contact No. : Mobile:
Office / Work Address : Sub-Caste
Contact No. :
Gotra
Mobile: Occupation( )
Email ID :
Fax:
Service
Business
Profession
Others (Specify)
District : Chapter:
I wish to be amember as follows:
100/- General Member 250/-Active Member 1000/- Super Active Member 11000/- Zonal Life Member
Enclosed Cheque/ CashNo.: Dated Drawn on
(Rupees
I agree with rules and Regulation of Vipra Foundation and shall devote my time, skill to do all the best for Vipra Foundation
Place: Date:
Signature of
Applicant:
FOR OFFICE USE ONLY
Receipt No.: Date: Amount: (Rupees
MEMBERSHIP ENROLLED:
100/- General Member 250/-Active Member 1000/- Super Active Member 11000/- Zonal Life Member
Membership No. : GM/ AM/ SAM/ ZLM/
Office Bearer's Signature:
ZONAL MEMBERSHIP FORM
(HARIYANA AND CHANDIGARH)
Zonal Office :
1124, S. P., Sector-46, Gurgaon-122003, Haryana
(Under clause 3(A), 3(B) and 3(C) of the regulation of Vipra Foundation)
PLEASE FILL IN CAPITAL LETTERS WITH BLACK INK Date: ___/__/____
Name : Date of Birth
Father’s / Husband’s Name : DD MM YYYY
Residential Address : Marriage Anniversary
DD MM YYYY
Native Place &
District
Contact No. : Mobile:
Office / Work Address : Sub-Caste
Contact No. :
Gotra
Mobile: Occupation( )
Email ID : Fax:
Service
Business
Profession
Others (Specify)
District : Chapter:
I wish to be amember as follows:
100/- General Member 250/-Active Member 1000/- Super Active Member 11000/- Zonal Life Member
Enclosed Cheque/ CashNo.: Dated Drawn on
(Rupees
I agree with rules and Regulation of Vipra Foundation and shall devote my time, skill to do all the best for Vipra Foundation
Place: Date: Signature of Applicant:
FOR OFFICE USE ONLY
Receipt No.: Date: Amount: (Rupees
MEMBERSHIP ENROLLED:
100/- General Member 250/-Active Member 1000/- Super Active Member 11000/- Zonal Life Member
Membership No. : GM/ AM/ SAM/ ZLM/
Office Bearer's Signature:
ZONAL MEMBERSHIP FORM
(UTAR PRADESH)
Zonal Office :
(Under clause 3(A), 3(B) and 3(C) of the regulation of Vipra Foundation)
PLEASE FILL IN CAPITAL LETTERS WITH BLACK INK Date: ___/__/____
Name : Date of Birth
Father’s / Husband’s Name : DD MM YYYY
Residential Address : Marriage Anniversary
DD MM YYYY
Native Place &
District
Contact No. : Mobile:
Office / Work Address : Sub-Caste
Contact No. :
Gotra
Mobile: Occupation( )
Email ID : Fax:
Service
Business
Profession
Others (Specify)
District : Chapter:
I wish to be amember as follows:
100/- General Member 250/-Active Member 1000/- Super Active Member 11000/- Zonal Life Member
Enclosed Cheque/ CashNo.: Dated Drawn on
(Rupees
I agree with rules and Regulation of Vipra Foundation and shall devote my time, skill to do all the best for Vipra Foundation
Place: Date: Signature of Applicant:
FOR OFFICE USE ONLY
Receipt No.: Date: Amount: (Rupees
MEMBERSHIP ENROLLED:
100/- General Member 250/-Active Member 1000/- Super Active Member 11000/- Zonal Life Member
Membership No. : GM/ AM/ SAM/ ZLM/
Office Bearer's Signature:
ZONAL MEMBERSHIP FORM
(BIHAR)
Zonal Office :
(Under clause 3(A), 3(B) and 3(C) of the regulation of Vipra Foundation)
PLEASE FILL IN CAPITAL LETTERS WITH BLACK INK Date: ___/__/____
Name : Date of Birth
Father’s / Husband’s Name : DD MM YYYY
Residential Address : Marriage Anniversary
DD MM YYYY
Native Place &
District
Contact No. : Mobile:
Office / Work Address : Sub-Caste
Contact No. :
Gotra
Mobile: Occupation( )
Email ID : Fax:
Service
Business
Profession
Others (Specify)
District : Chapter:
I wish to be amember as follows:
100/- General Member 250/-Active Member 1000/- Super Active Member 11000/- Zonal Life Member
Enclosed Cheque/ CashNo.: Dated Drawn on
(Rupees
I agree with rules and Regulation of Vipra Foundation and shall devote my time, skill to do all the best for Vipra Foundation
Place: Date: Signature of Applicant:
FOR OFFICE USE ONLY
Receipt No.: Date: Amount: (Rupees
MEMBERSHIP ENROLLED:
100/- General Member 250/-Active Member 1000/- Super Active Member 11000/- Zonal Life Member
Membership No. : GM/ AM/ SAM/ ZLM/
Office Bearer's Signature:
ZONAL MEMBERSHIP FORM
(JHARKHAND)
Zonal Office :
Subhas Chowk, Toongri, Chaibasa, Singhbhoom-833201, Jharkhand
(Under clause 3(A), 3(B) and 3(C) of the regulation of Vipra Foundation)
PLEASE FILL IN CAPITAL LETTERS WITH BLACK INK Date: ___/__/____
Name : Date of Birth
Father’s / Husband’s Name : DD MM YYYY
Residential Address : Marriage Anniversary
DD MM YYYY
Native Place &
District
Contact No. : Mobile:
Office / Work Address : Sub-Caste
Contact No. :
Gotra
Mobile: Occupation( )
Email ID : Fax:
Service
Business
Profession
Others (Specify)
District : Chapter:
I wish to be amember as follows:
100/- General Member 250/-Active Member 1000/- Super Active Member 11000/- Zonal Life Member
Enclosed Cheque/ CashNo.: Dated Drawn on
(Rupees
I agree with rules and Regulation of Vipra Foundation and shall devote my time, skill to do all the best for Vipra Foundation
Place: Date: Signature of Applicant:
FOR OFFICE USE ONLY
Receipt No.: Date: Amount: (Rupees
MEMBERSHIP ENROLLED:
100/- General Member 250/-Active Member 1000/- Super Active Member 11000/- Zonal Life Member
Membership No. : GM/ AM/ SAM/ ZLM/
Office Bearer's Signature:
ZONAL MEMBERSHIP FORM
(WEST BENGAL AND SIKKIM)
Zonal Office :
Gillander House, Block-E, 3rd Floor, R.No. 2A, 8, N. S. Road, Kolkata-700001 (WB)
(Under clause 3(A), 3(B) and 3(C) of the regulation of Vipra Foundation)
PLEASE FILL IN CAPITAL LETTERS WITH BLACK INK Date: ___/__/____
Name : Date of Birth
Father’s / Husband’s Name : DD MM YYYY
Residential Address : Marriage Anniversary
DD MM YYYY
Native Place &
District
Contact No. : Mobile:
Office / Work Address : Sub-Caste
Contact No. :
Gotra
Mobile: Occupation( )
Email ID : Fax:
Service
Business
Profession
Others (Specify)
District : Chapter:
I wish to be amember as follows:
100/- General Member 250/-Active Member 1000/- Super Active Member 11000/- Zonal Life Member
Enclosed Cheque/ CashNo.: Dated Drawn on
(Rupees
I agree with rules and Regulation of Vipra Foundation and shall devote my time, skill to do all the best for Vipra Foundation
Place: Date: Signature of Applicant:
FOR OFFICE USE ONLY
Receipt No.: Date: Amount: (Rupees
MEMBERSHIP ENROLLED:
100/- General Member 250/-Active Member 1000/- Super Active Member 11000/- Zonal Life Member
Membership No. : GM/ AM/ SAM/ ZLM/
Office Bearer's Signature:
ZONAL MEMBERSHIP FORM
(ASSAM,ARUNACHAL PRADESH, NAGALAND,MANIPUR, AND MEGHALAYA)
Zonal Office :
Kamlakunj, 6th Floor, Assam Ispat Complex, n. S. Road, Fatasil, Guwahati-781009
(Under clause 3(A), 3(B) and 3(C) of the regulation of Vipra Foundation)
PLEASE FILL IN CAPITAL LETTERS WITH BLACK INK Date: ___/__/____
Name : Date of Birth
Father’s / Husband’s Name : DD MM YYYY
Residential Address : Marriage Anniversary
DD MM YYYY
Native Place &
District
Contact No. : Mobile:
Office / Work Address : Sub-Caste
Contact No. :
Gotra
Mobile: Occupation( )
Email ID : Fax:
Service
Business
Profession
Others (Specify)
District : Chapter:
I wish to be amember as follows:
100/- General Member 250/-Active Member 1000/- Super Active Member 11000/- Zonal Life Member
Enclosed Cheque/ CashNo.: Dated Drawn on
(Rupees
I agree with rules and Regulation of Vipra Foundation and shall devote my time, skill to do all the best for Vipra Foundation
Place: Date: Signature of Applicant:
FOR OFFICE USE ONLY
Receipt No.: Date: Amount: (Rupees
MEMBERSHIP ENROLLED:
100/- General Member 250/-Active Member 1000/- Super Active Member 11000/- Zonal Life Member
Membership No. : GM/ AM/ SAM/ ZLM/
Office Bearer's Signature:
ZONAL MEMBERSHIP FORM
(VIDARBH)
Zonal Office :
17, Giripeth, Opp: RTO Office, Nagpur-440002 (Maharashtra)
(Under clause 3(A), 3(B) and 3(C) of the regulation of Vipra Foundation)
PLEASE FILL IN CAPITAL LETTERS WITH BLACK INK Date: ___/__/____
Name : Date of Birth
Father’s / Husband’s Name : DD MM YYYY
Residential Address : Marriage Anniversary
DD MM YYYY
Native Place &
District
Contact No. : Mobile:
Office / Work Address : Sub-Caste
Contact No. :
Gotra
Mobile: Occupation( )
Email ID : Fax:
Service
Business
Profession
Others (Specify)
District : Chapter:
I wish to be amember as follows:
100/- General Member 250/-Active Member 1000/- Super Active Member 11000/- Zonal Life Member
Enclosed Cheque/ CashNo.: Dated Drawn on
(Rupees
I agree with rules and Regulation of Vipra Foundation and shall devote my time, skill to do all the best for Vipra Foundation
Place: Date: Signature of Applicant:
FOR OFFICE USE ONLY
Receipt No.: Date: Amount: (Rupees
MEMBERSHIP ENROLLED:
100/- General Member 250/-Active Member 1000/- Super Active Member 11000/- Zonal Life Member
Membership No. : GM/ AM/ SAM/ ZLM/
Office Bearer's Signature:
ZONAL MEMBERSHIP FORM
(ORISSA)
Zonal Office :
Near Axis Bank, Gujarati Colony, Kach hari Road, Rourkela-751012 (Orissa)
(Under clause 3(A), 3(B) and 3(C) of the regulation of Vipra Foundation)
PLEASE FILL IN CAPITAL LETTERS WITH BLACK INK Date: ___/__/____
Name : Date of Birth
Father’s / Husband’s Name : DD MM YYYY
Residential Address : Marriage Anniversary
DD MM YYYY
Native Place &
District
Contact No. : Mobile:
Office / Work Address : Sub-Caste
Contact No. :
Gotra
Mobile: Occupation( )
Email ID : Fax:
Service
Business
Profession
Others (Specify)
District : Chapter:
I wish to be amember as follows:
100/- General Member 250/-Active Member 1000/- Super Active Member 11000/- Zonal Life Member
Enclosed Cheque/ CashNo.: Dated Drawn on
(Rupees
I agree with rules and Regulation of Vipra Foundation and shall devote my time, skill to do all the best for Vipra Foundation
Place: Date: Signature of Applicant:
FOR OFFICE USE ONLY
Receipt No.: Date: Amount: (Rupees
MEMBERSHIP ENROLLED:
100/- General Member 250/-Active Member 1000/- Super Active Member 11000/- Zonal Life Member
Membership No. : GM/ AM/ SAM/ ZLM/
Office Bearer's Signature:
ZONAL MEMBERSHIP FORM
(PUNJAB, HIMACHAL PRADESH, JAMMU & KASHMIR AND UTTRANCHAL)
Zonal Office :
House No. 228, Gali No. 7, post: Abohar, Dist: Fazilka-152116 (Punjab)
(Under clause 3(A), 3(B) and 3(C) of the regulation of Vipra Foundation)
PLEASE FILL IN CAPITAL LETTERS WITH BLACK INK Date: ___/__/____
Name : Date of Birth
Father’s / Husband’s Name : DD MM YYYY
Residential Address : Marriage Anniversary
DD MM YYYY
Native Place &
District
Contact No. : Mobile:
Office / Work Address : Sub-Caste
Contact No. :
Gotra
Mobile: Occupation( )
Email ID : Fax:
Service
Business
Profession
Others (Specify)
District : Chapter:
I wish to be amember as follows:
100/- General Member 250/-Active Member 1000/- Super Active Member 11000/- Zonal Life Member
Enclosed Cheque/ CashNo.: Dated Drawn on
(Rupees
I agree with rules and Regulation of Vipra Foundation and shall devote my time, skill to do all the best for Vipra Foundation
Place: Date: Signature of Applicant:
FOR OFFICE USE ONLY
Receipt No.: Date: Amount: (Rupees
MEMBERSHIP ENROLLED:
100/- General Member 250/-Active Member 1000/- Super Active Member 11000/- Zonal Life Member
Membership No. : GM/ AM/ SAM/ ZLM/
Office Bearer's Signature:
ZONAL MEMBERSHIP FORM
(MAHARASHTRA AND GOA)
Zonal Office :
Goregaon East,922-23, Corporate Avenue, Sonawala Road Mumbai-400063
(Under clause 3(A), 3(B) and 3(C) of the regulation of Vipra Foundation)
PLEASE FILL IN CAPITAL LETTERS WITH BLACK INK Date: ___/__/____
Name : Date of Birth
Father’s / Husband’s Name : DD MM YYYY
Residential Address : Marriage Anniversary
DD MM YYYY
Native Place &
District
Contact No. : Mobile:
Office / Work Address : Sub-Caste
Contact No. :
Gotra
Mobile: Occupation( )
Email ID : Fax:
Service
Business
Profession
Others (Specify)
District : Chapter:
I wish to be amember as follows:
100/- General Member 250/-Active Member 1000/- Super Active Member 11000/- Zonal Life Member
Enclosed Cheque/ CashNo.: Dated Drawn on
(Rupees
I agree with rules and Regulation of Vipra Foundation and shall devote my time, skill to do all the best for Vipra Foundation
Place: Date: Signature of Applicant:
FOR OFFICE USE ONLY
Receipt No.: Date: Amount: (Rupees
MEMBERSHIP ENROLLED:
100/- General Member 250/-Active Member 1000/- Super Active Member 11000/- Zonal Life Member
Membership No. : GM/ AM/ SAM/ ZLM/
Office Bearer's Signature:
ZONAL MEMBERSHIP FORM
(CHHATISGARH)
Zonal Office :
Madhav Mandir Chowk, Rajnandgaon-491441, Chhatisgarh
(Under clause 3(A), 3(B) and 3(C) of the regulation of Vipra Foundation)
PLEASE FILL IN CAPITAL LETTERS WITH BLACK INK Date: ___/__/____
Name : Date of Birth
Father’s / Husband’s Name : DD MM YYYY
Residential Address : Marriage Anniversary
DD MM YYYY
Native Place &
District
Contact No. : Mobile:
Office / Work Address : Sub-Caste
Contact No. :
Gotra
Mobile: Occupation( )
Email ID : Fax:
Service
Business
Profession
Others (Specify)
District : Chapter:
I wish to be amember as follows:
100/- General Member 250/-Active Member 1000/- Super Active Member 11000/- Zonal Life Member
Enclosed Cheque/ CashNo.: Dated Drawn on
(Rupees
I agree with rules and Regulation of Vipra Foundation and shall devote my time, skill to do all the best for Vipra Foundation
Place: Date: Signature of Applicant:
FOR OFFICE USE ONLY
Receipt No.: Date: Amount: (Rupees
MEMBERSHIP ENROLLED:
100/- General Member 250/-Active Member 1000/- Super Active Member 11000/- Zonal Life Member
Membership No. : GM/ AM/ SAM/ ZLM/
Office Bearer's Signature:
ZONAL MEMBERSHIP FORM
(MADHYA PRADESH)
Zonal Office :
13, Swapanlok Colony, 2/11, South Tucoganj, Indore-452001, Gujarat
(Under clause 3(A), 3(B) and 3(C) of the regulation of Vipra Foundation)
PLEASE FILL IN CAPITAL LETTERS WITH BLACK INK Date: ___/__/____
Name : Date of Birth
Father’s / Husband’s Name : DD MM YYYY
Residential Address : Marriage Anniversary
DD MM YYYY
Native Place &
District
Contact No. : Mobile:
Office / Work Address : Sub-Caste
Contact No. :
Gotra
Mobile: Occupation( )
Email ID : Fax:
Service
Business
Profession
Others (Specify)
District : Chapter:
I wish to be amember as follows:
100/- General Member 250/-Active Member 1000/- Super Active Member 11000/- Zonal Life Member
Enclosed Cheque/ CashNo.: Dated Drawn on
(Rupees
I agree with rules and Regulation of Vipra Foundation and shall devote my time, skill to do all the best for Vipra Foundation
Place: Date: Signature of Applicant:
FOR OFFICE USE ONLY
Receipt No.: Date: Amount: (Rupees
MEMBERSHIP ENROLLED:
100/- General Member 250/-Active Member 1000/- Super Active Member 11000/- Zonal Life Member
Membership No. : GM/ AM/ SAM/ ZLM/
Office Bearer's Signature:
ZONAL MEMBERSHIP FORM
(GUJARAT, DAMAN& DIU AND NAGAR HAWELI)
Zonal Office :
A-803, Surya Plaza Society, Udanamadgala Road,Bhatter, Surat-395007, Gujarat
(Under clause 3(A), 3(B) and 3(C) of the regulation of Vipra Foundation)
PLEASE FILL IN CAPITAL LETTERS WITH BLACK INK Date: ___/__/____
Name : Date of Birth
Father’s / Husband’s Name : DD MM YYYY
Residential Address : Marriage Anniversary
DD MM YYYY
Native Place &
District
Contact No. : Mobile:
Office / Work Address : Sub-Caste
Contact No. :
Gotra
Mobile: Occupation( )
Email ID : Fax:
Service
Business
Profession
Others (Specify)
District : Chapter:
I wish to be amember as follows:
100/- General Member 250/-Active Member 1000/- Super Active Member 11000/- Zonal Life Member
Enclosed Cheque/ CashNo.: Dated Drawn on
(Rupees
I agree with rules and Regulation of Vipra Foundation and shall devote my time, skill to do all the best for Vipra Foundation
Place: Date: Signature of Applicant:
FOR OFFICE USE ONLY
Receipt No.: Date: Amount: (Rupees
MEMBERSHIP ENROLLED:
100/- General Member 250/-Active Member 1000/- Super Active Member 11000/- Zonal Life Member
Membership No. : GM/ AM/ SAM/ ZLM/
Office Bearer's Signature:
ZONAL MEMBERSHIP FORM
(ANDHRA PRADESH, ANDAMAN AND NICOBAR ISLAND )
Zonal Office :
15-8-450, K. K. Complex, Pheelkhana, Hyderabad-500012, Andhra Pradesh
(Under clause 3(A), 3(B) and 3(C) of the regulation of Vipra Foundation)
PLEASE FILL IN CAPITAL LETTERS WITH BLACK INK Date: ___/__/____
Name : Date of Birth
Father’s / Husband’s Name : DD MM YYYY
Residential Address : Marriage Anniversary
DD MM YYYY
Native Place &
District
Contact No. : Mobile:
Office / Work Address : Sub-Caste
Contact No. :
Gotra
Mobile: Occupation( )
Email ID : Fax:
Service
Business
Profession
Others (Specify)
District : Chapter:
I wish to be amember as follows:
100/- General Member 250/-Active Member 1000/- Super Active Member 11000/- Zonal Life Member
Enclosed Cheque/ CashNo.: Dated Drawn on
(Rupees
I agree with rules and Regulation of Vipra Foundation and shall devote my time, skill to do all the best for Vipra Foundation
Place: Date: Signature of Applicant:
FOR OFFICE USE ONLY
Receipt No.: Date: Amount: (Rupees
MEMBERSHIP ENROLLED:
100/- General Member 250/-Active Member 1000/- Super Active Member 11000/- Zonal Life Member
Membership No. : GM/ AM/ SAM/ ZLM/
Office Bearer's Signature:
ZONAL MEMBERSHIP FORM
(TAMILNADU AND PONDICHERRY)
Zonal Office :
17, Odiyappanayakan Street, Sahukar Pett, Chennai-6000079, Tamilnadu
(Under clause 3(A), 3(B) and 3(C) of the regulation of Vipra Foundation)
PLEASE FILL IN CAPITAL LETTERS WITH BLACK INK Date: ___/__/____
Name : Date of Birth
Father’s / Husband’s Name : DD MM YYYY
Residential Address : Marriage Anniversary
DD MM YYYY
Native Place &
District
Contact No. : Mobile:
Office / Work Address : Sub-Caste
Contact No. :
Gotra
Mobile: Occupation( )
Email ID : Fax:
Service
Business
Profession
Others (Specify)
District : Chapter:
I wish to be amember as follows:
100/- General Member 250/-Active Member 1000/- Super Active Member 11000/- Zonal Life Member
Enclosed Cheque/ CashNo.: Dated Drawn on
(Rupees
I agree with rules and Regulation of Vipra Foundation and shall devote my time, skill to do all the best for Vipra Foundation
Place: Date: Signature of Applicant:
FOR OFFICE USE ONLY
Receipt No.: Date: Amount: (Rupees
MEMBERSHIP ENROLLED:
100/- General Member 250/-Active Member 1000/- Super Active Member 11000/- Zonal Life Member
Membership No. : GM/ AM/ SAM/ ZLM/
Office Bearer's Signature:
ZONAL MEMBERSHIP FORM
(KERALA,KARNATAKA AND LAKSHDWEEP)
Zonal Office :
Dakshin Bharat Rashtramat, 6/4, Cantonment Station Road, Bangaluru-560051
(Under clause 3(A), 3(B) and 3(C) of the regulation of Vipra Foundation)
PLEASE FILL IN CAPITAL LETTERS WITH BLACK INK Date: ___/__/____ .
Name : Date of Birth
Father’s / Husband’s Name : DD MM YYYY
Residential Address : Marriage Anniversary
DD MM YYYY
Native Place &
District
Contact No. : Mobile:
Office / Work Address : Sub-Caste
Contact No. :
Gotra
Mobile: Occupation( )
Email ID : Fax:
Service
Business
Profession
Others (Specify)
District : Chapter:
I wish to be amember as follows:
100/- General Member 250/-Active Member 1000/- Super Active Member 11000/- Zonal Life Member
Enclosed Cheque/ CashNo.: Dated Drawn on
(Rupees
I agree with rules and Regulation of Vipra Foundation and shall devote my time, skill to do all the best for Vipra Foundation
Place: Date: Signature of Applicant:
FOR OFFICE USE ONLY
Receipt No.: Date: Amount: (Rupees
MEMBERSHIP ENROLLED:
100/- General Member 250/-Active Member 1000/- Super Active Member 11000/- Zonal Life Member
Membership No. : GM/ AM/ SAM/ ZLM/
Office Bearer's Signature:
