Membership Form

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GANDHI SAMAJ
OF SOUTH GUJARAT

Membership Form Year:
____________

 

Membership
(Please check one): Lifetime: ________ Annual: __________

 

Last
name: ____________________________ Mr./Mrs./Ms./Miss

 

First
name: ____________________________ Middle Initial: ___________

 

Spouse’s
name: ____________________________

 

Children’s Name(s): ____________________________ Son/Daughter DoB: ______

 

__________________________ Son/Daughter
DoB: ______

 

____________________________ Son/Daughter
DoB: ______

 

____________________________
Son/Daughter DoB: ______

 

Address: ______________________________________________________

 

______________________________________________________

______________________________________________________

 

Phone#:
(H) ______________________ (C) ___________________________

 

Fax#:
______________________ (W)
___________________________

 

E-Mail: _______________________________________________________

 

Father’s
Name: ______________________ Mother’s Name: _________________

 

Native
Place in India: ______________________________________________________

 

Signature: __________________________
Date: _____/_____/________

 

For Office Use Only. Membership
Number:___________ Amount: $____________