Request Form for User Registration

(Form C)
User Details
User ID

purnarogya108

Name

Sanjay Pisharodi

Gender

Male

Date of birth

27/07/1973

Designation

Doctor

Email id

drsanjay@purnarogya.com

Mobile

9947084499

Phone no

04936-243003

Nationality

INDIA

Hotel / Guest House / Dharamshala / Institute / Individual House / etc. Details

Name

Purnarogya

Capacity

Address

Dr Sanjay Pisharodi, House number MP XV/24B, Mullankolly P.O, Pulpally, Waynad - 673579

State

KERALA

Accomodation type

Individual House

Accomodation grade

Others

Email id

drsanjay@purnarogya.com

Mobile

9947084499

Phone no

04936-243003

City/District

WAYANAD

City/District

WAYANAD

Owner's Details
Name

Sanjay Pisharodi

Address

H. No. MP XV/24B, Mullalkolly P. O, Pulpally

State

KERALA

Email id

drsanjay@purnarogya.com

Mobile

9947084499

Phone no

04936-243003

_______________
Signature of the Applicant
Date-------------------Place--------------------

_______________
Name and Signature of Hotel / Guest House / Dharamshala / Institute / Individual House / etc.
Date-------------------Place-------------------Registration office address
Office Name

FRO WAYANAD

Address

District Police Chief,Wayanad,North Kalpetta PO

City/ District

WAYANAD

State

KERALA

Pin Code

673122

Phone Number

202525