: If you desire to associate with this Environment oriented Institution, fill the form given below and submit
MEMBERSHIP APPLICATION FORM
To,
The Member Secretary,
PED PANCHAYAT,
328, M.I.G. Flats, East of Loni Road
Delhi- 110093.
Sub : Application for Membership of Ped Panchayat
Name (in Hindi) : __________________________________________________________
Name (in English) : __________________________________________________________
Father’s Name :___________________________________________________________
Mother’ Name :___________________________________________________________
Gender : Male / Female ______________________________________
Date of Birth/Age :
Address : __________________________________________________________
: __________________________________________________________
: __________________________________________________________
Pin Code : ______________________________
(Attach a self attested copy of each of your Aadhar Card/Passport/DL and PAN)
Telephone Nos. : _____________________________Fax No. : ________________
Web site (if any) : __________________________E-Mail : _____________________________
Academic
and Professional Qualifications, if any:
_________________________________________________________________________________
Profession :____________________________________________________________________
Name and address of the organisation (if any): ____________________________________________________________________________________________________________________________________________________________________
Category of Membership sought: ___________________________________________ (Life Membership: INR 5000 / Ordinary Membership: INR 500 and annually INR 50)
Details of Membership fee sent: ______________________________________________ (send payments in the name Ped Panchayat payable at Delhi through DD/NEFT/Cash etc.)
Purpose for which Membership is sought:
_________________________________________________________________________________
__________________________________________________________________________________
Any other Information: __________________________________________________________
DECLARATION :
I am desirous of becoming member of Ped Panchayat and I undertake that I shall abide by the rules and regulations of the society.
The information furnished above is true & correct to the best of my knowledge and belief and is based on facts. Nothing material has been concealed/misrepresented therein. If any information furnished above is found to be false or misleading, concealed or suppressed, undersigned will be liable for the consequences thereof.
Signature : …………………………
Dated :