Form for enrolling as an associate member of
‘Smt.Nandini Satpathy Memorial Committee’.
Committee
name:
only for office use
Name:
Mr./ Mrs./ Ms.:
Fathers/
Husbands name :
Date
of Birth
Place
of Birth
Residence
address
Phone
No. (Res)
Mobile
No.
Office
address
Designation
Phone
No. (office)
Fax
No.
Email
id
Permanent
address
(Tick
the address you would want all your correspondence at)
Name
of Spouse Mr./Mrs.
Occupation
of Spouse
Name
(s) of dependent Children
a)
b)
c)
Pan
Card No.
Pass
Port No.
Driving
License No.
a)
Have you read intent of ‘Smt.Nandini Satpathy Memorial Trust’?
Y /
N.
b)
Why do you want to be a part of Smt. Nandini Satpathy Memorial
Committee?
c)
Brief description about education background of self &
your spouse
d)
Brief description about your professional background of self
& your spouse
e)
Are you an existing member of any club / Society/Trust/ NGO?
Y /
N
If
yes then give details
The
Chairman,
Smt. Nandini Satpathy Memorial Trust.
Sundarikhal, Dhenkanal, Orissa, India
Sir,
I
hereby certify that all the above-mentioned information is
true. I am interested in joining
the Smt. Nandini Satpathy Memorial -Committee for a noble
cause . Kindly find my contribution of Rs.51,000/-
(Fifty One Thousand Rupees Only)
DD / Cheque No.
Dated
Bank
Branch
I
am aware of the aims & objectives of Smt. Nandini Satpathy
Memorial Trust . I am also
aware of the rules & regulations of the said trust. I
pledge to abide by them.
Signatures
Name
Date
Member
Reference :Name
Note:
-
i.
Attach
two self-attested current dated photographs of self, spouse
and dependent
children along with this application form.
ii.
Cheque
/ DD to be made in favor of "Smt.Nandini Satpathy
Memorial Trust"
iii.
Kindly
fax the copy of this application form (duly filled) along
with the copy of
DD / Cheque to fax no. +91.674.253.6262. On approval
of your application the originals
of the same will be collected from you in person.(Please
do not send payment in advance)
