Membership form of Chotiwala's Ayurveda Surgical & Yoga Research Centre

(A unit of Chotiwala Ayurveda & Yoga Samiti, 492, C. P. Mission Compound, Near Preeti Provisional Store, Gwaliar Road, Jhansi - 284003)

Serial No.
Membership Code :
Receipt No.

(To be filled by the office)

To,
The Secretary,
Chotiwala Ayurveda & Yoga Samiti,

492, C. P. Mission Compound, Near Preeti Provisional Store, Gwaliar Road, Jhansi - 284003
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Sir,
I S/o- W/o-D/o do hereby request you to grant me membership in the following category : (Tick whichever is applicable)
Founder Member
Patron Member
Life Member
Dignified Member
Respected Member
General Member
Other
Member's Particulars
1.
Name
2.
Sex
Male Female
3.
Father's /Husband's Name
4.
Age
5.
D.O.B
6.
Qualification
7.
Occupation
8.
Permanent Address
9.
Address for orrespondence
10.
Phone No. Residence with S.T.D.
-
11.
Phone No. Office with S.T.D
-
12.
Mobile No.
13.
Email
14.
PAN No. (With designation of Officer-Circle/Ward/Place)
Declaration
I have read all the rules and regulations regarding the membership of Chotiwala's Ayurveda Surgical & Yoga Research Centre elaborated after the application form and objectives of Chotiwala Ayurveda & Yoga Samiti attached with the application form. I shall abide by the concerned rules and regulations concerned. In the event of violation of concerned rules and regulations under any circumstances by me, the Chotiwala Ayurveda & Yoga Samiti is independent to take any disciplinary action against me without assigning any reason thereof and I shall be entirely responsible for it. I,now,request you to enroll me as a member as per rules and regulations of the Chotiwala Ayurveda & Yoga Samiti.

Signature of Applicant