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Form for enrolling as an associate member of ‘Smt.Nandini Satpathy Memorial Committee’.


Name: Mr./ Mrs./ Ms.:
Fathers/ Husbands name :
Date of Birth
Place of Birth
Residence address
Phone No. (Res)
Mobile No.
Office address
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)

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


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.


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)
iv. Optionally you can submit this form online.