(MEMBERSHIP FORM)
Applicant’s recent passport size photo should be affixed here	

            Registration No.: 
                                        (For office use only)

I  _________________________________  S/o  _____________________________                  want to become  Ordinary Member  of Indore society for organ donation , I have carefully read the rules , regulation and bye-laws of society and undertake to abide by all these rules  , regulation and bye-laws of society as in force and any subsequent amendment(s) made from time to time. I am submitting  my brief particulars  which are as under :- 
Sr	PARTICULARS	DETAILS	
1	Name of Applicant		
2	Fathers/ Husband Name		
3	Date of Birth		
4	Date of Marriage		
5	Qualification		
6	Blood Group		
7	Sex		
8	Nationality		
9	Contact No. :- Mobile		
A	Land line Office		
B	Land line Residence		
10	Occupation		
A	If in service
(Designation and Name of Organization)		
B	If in Business
(Name of firm & Nature of business)		
11	Address		
A	Residential Address		
B	Office Address		
12	Personal Details		
A	PAN No.		
B	Passport No.		
C	Voter ID		

PAYMENT DETAILS MEMBERSHIP FEES

Sr	PARTICULARS	REMARK	
			
1	Amount in figures		
	Amount in Word		
	Mode of payment 
(Cash/ Cehque)		
	Cheque No.		
	Date		
	Drawn on		

      I __________________________________     S/o  or D/o _________________________________        undertake that
1] I will not represent any body as representative of society unless I have been authorized in writing by the governing body of society.
2] I will not do any act which is against the rules, regulation , bye-laws and intention of society.
3] I am of the sound mind and not declare insolvent .
4] That I have not been convicted by any court in India for any offence .
4] That no proceeding in respect of any criminal offence alleged to have been committed by me are pending before any criminal court in India.

	Signature	
	
	Name		

DECLARATION/VERIFICATION

I ______________________________________    S/o or D/o ____________________________________   do hereby declare that  the above details are true and correct to the best of my knowledge and belief , no material information have been concealed . I  wish to be ordinary  member of Indore society  for Organ Donation . I have carefully read and understand the instructions overleaf and Bye-Laws of Indore  society  for Organ Donation . I shall abide by these Rules, Regulation &  Bye-Laws of the Society as in force and any subsequent amendment(s) made from time to time. I here by confirm that in case of any default in complying with my duties as ordinary member of society or doing any act against the object of society or violation of rules , regulation or bye-laws of society then governing body can terminate my membership without assigning  any reason.  *
 LIST OF DOCUMENTS TO BE ENCLOSED ALONG WITH MEMBERSHIP FORM

Sr	PARTICULARS	DETAILS	
	 ID PROOF		
1	PAN Card		
2	Voter ID Card		
3	Passport		
	ADDRESS PROOF		
1	Telephone Bill		
2	Electricity Bill		
3	Passport