Untitled Document

MEMBER REGISTRATION FORM
(Please fill in all the fields)

*First Name	:
*Surname	:
*Gender	:	Male Female (tick on the appropriate)
Email Id	:
Mobile No.	:
Address	:
Pin code	:
City	:
State	:
Country	:
*Amount Contribution: Rs.	:	Total Amount (Rs.) :
*Period of contribution	:	One time Monthly Quarterly Half yearly Annually
Initial payment mode	:	Cheque Cash DD Others

Reminder facility required for your donation payments
Mobile SMS facility	:	Yes No (tick on the appropriate)
Email facility	:	Yes No (tick on the appropriate)
Do you agree to ECS facility in future as a mode of your donation payment?	:	Yes No (tick on the appropriate)