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Membership Of Indian Red Cross
 
             
INDIAN RED CROSS SOCIETY
Gujarat State Branch
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:
 
Name :      
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First Name
Middle Name
Surname
Date of Birth:
dd/mm/yyyy
Enrollment with IRCS Branch :  
Type of Membership :  
Date of Enrollment :  
Residence Address:
Business Address:
Address:   Title:  
    Address:  
City/Village      
District                  Pincode: Ctiy/Village  
State   District                  Pincode:
Phone with area code:   State:  
Mobile:   Phone with area code:  
Email:   Mobile:  
               
Declaration            
I hereby certify that the above information is correct and complete.
_______________ ________________________                 ________________________
Date   Place                  Signature of Member  
FOR OFFICE USE ONLY:
TO BE FIELD BY THE CONCERN BRANCH OF INDIAN RED CROSS SOCIETY:
Category of membership desired: Tick here Amount Rs.  
a)      Patron (   ) Rs.20,000/-  
b)      Vice Patron (   ) Rs.10,000/-  
c)      Life Member (   ) Rs.500/-  
d)      Life Associate Member (   ) Rs.250/-  
e)      Annual Member (   ) Rs.100/-  
f)        Annual Associate Member (   ) Rs.50/-  
g)      Institutional Member (   ) Rs.5,000/-  
(For Company/firm only)  
   
I hereby confirm that the above information of the Member of our branch is correct and best to the my knowledge.
______________ ___________________________                        __________________
Date   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.