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Gujarat State Branch |
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Red Cross Bhavan, Nr. Khadi Gramodhyog Board |
Ashram Road, Old Wadaj, Ahmedabad-380013 |
Ph. + 91-79-27557055/56, Mobile-942635004 |
Email: ircsguj@hotmail.com Website: www.redcrossgujarat.org |
MEMBERSHIP ENROLMENT FORM |
ALL INFORMATION MUST BE FILLED IN CAPITALS: |
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| Name : |
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Affix your
recent pasport size color photograph here |
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First Name |
Middle Name |
Surname |
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| Date of Birth: |
dd/mm/yyyy |
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| Enrollment with IRCS Branch : |
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| Type of Membership : |
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| Date of Enrollment : |
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Residence Address: |
Business Address: |
| Address: |
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Title: |
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Address: |
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| City/Village |
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| District |
Pincode: |
Ctiy/Village |
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| State |
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District |
Pincode: |
| Phone with area code: |
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State: |
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| Mobile: |
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Phone with area code: |
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| Email: |
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Mobile: |
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| Declaration |
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| I hereby certify that the above information is correct and complete. |
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________________________ |
________________________ |
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Place |
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Signature of Member |
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| FOR OFFICE USE ONLY: |
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TO BE FIELD BY THE CONCERN BRANCH OF INDIAN RED CROSS SOCIETY: |
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| Category of membership desired: |
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Tick here |
Amount Rs. |
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| a) Patron |
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Rs.20,000/- |
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| b) Vice Patron |
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Rs.10,000/- |
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| c) Life Member |
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Rs.500/- |
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| d) Life Associate Member |
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Rs.250/- |
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| e) Annual Member |
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Rs.100/- |
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| f) Annual Associate Member |
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Rs.50/- |
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| g) Institutional Member |
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Rs.5,000/- |
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| (For Company/firm only) |
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I hereby confirm that the above information of the Member of our branch is correct and best to the my knowledge. |
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Signature of President/Secretary |
SEAL of Branch |
Note: This form is meant to update the information of Red Cross Members and it is mandatory as directed by National Headquarters. |
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