MEMBERSHIP FORM

Form No. :

Dear Sir,
I/we wish to apply for the membership of M.P. Bangiya Parishad and details of my/our profile mentioned below.
(Please read carefully the Constitution of this society before taking membership. The Constitution is available on demand only)

Select Membership Category Life Membership Patron Society Individual

Name ...............................................................................................……………………………………………… Sex ……………….........
Date of Birth........………………………………………………………… Place of Birth ...................................................................................
Present Addres………………………………………………..............................................................................……………………………………………
Permanent Address …………………………..............................................................................………………………………………………………..
Telephone No. Residence ................................. Office………………................................. Mobile …………...………….......................
E-mail ………………………………………..................................... Profession……………………………………………………………………………….............
Qualification(s) …………………………………………………………………...............................................................................………………………
Interests (Cultural/Social Activities/Others) .....................................................................................................................

Declaration:
I have understood Rules and Regulations of the Association and do agree to adhere to the same.
Date : …………………………………………
Place :………………………………………….

Signature
PLEASE PROVIDE FOLLOWING DETAILS FOR SOCIETY MEMBERSHIP

Name of the Organization ……………………………………………………………………………...........…………………………..……………………………………………..

Registration No. ……………………………………………………………………………………………..……………………………………………………..............................
Address for Communication ……………………………………...........................………………………………………………………………………………………………
Telephone No. …………………………………………… Office ………………………………………… Fax No. …………………………..............................…………
E-mail and website ……………………………………………….............………………...........................…………………………………………………………………
Total Membership Strength as on date ………………………………............……………………………………………………………………………………………………
Major Activities throughout the year ……………………………....................................………………………………………………………………………………
Special Activity, if any ……………………………..........................…………………………………………………………………………………………………………………
Reasons for joining with M.P. Bangiya Parishad …………………………………………………………………………………………....................................

Declaration:
I/we have understood Rules and Regulations of the Association and do agree to adhere to the same. A list of present Executive
body members is attached.
Date :
Place
Signature of Secretary/President

MEMBERSHIP FEES: Patron - Rs. 12000/-, Life Member - Rs. 6000/-, Society - Rs. 10000/-, Individual - Rs. 600/-
Membership Fees may be remitted by Crossed A/c Payee Cheque/Demand Draft in favour of M.P. Bangiya Parishad,
Bhopal OR directly to the Bank Account No. 900510110006371, Bank of India, Sachivalaya Branch, Bhopal

FOR OFFICE USE

Membership Status Details:

Date

Place

Signature of President Signature of Secretary