HAZARIBAG OLD XAVERIANS ASSOCIATION

Reunion 2013
25th - 27th January 2013
St. Xaviers School, Hazaribag - 825301, Jharkhand, INDIA
E-mail: hoxahzb@gmail.com

REGISTRATION FORM
Name : ...................................................
Surname

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First Name

Gender : (Tick One)

Female

Male

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Middle Name

Name of Spouse : ....................................................................................................

No. of Children : ................
[If spouse and children will be attending]
Year of Leaving the School : .............................................................................................................................................
Correspondence Address : ..............................................................................................................................................
............................................................................................................................... Postal Code : .....................................
Phone No. : .............................................................................. Cell No. : ........................................................................
Email : ................................................................................................................................................................................
Occupation : .......................................................................................................................................................................
Food Preference : (Tick One)

Vegetarian

Non Vegetarian

Arrival :

Date : ...................................................

Time : ...................................................

Departure :

Date : ...................................................

Time : ...................................................

Payment Details : DD / Cheque No. .................................................................. Date ............................................ for

Rs. ................................................... Drawn on ......................................................................................................Bank
In favour of HOXA [Payable at Hazaribag]
For those who wish to make a direct bank deposit AXIS Bank A/c No. 910010027445252 IFSC code - UTIB0000613 Branch: Ravindra Path, Hazaribag
Bank of India - A/c No. 588310110000894 FISC - BKID 0005883, Branch: Vinoba Bhave University, Hazaribag
Date of Making Deposit : ................................................. Please attach the proof of payment along with this from

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Date

...................................................
Place

...................................................
Signature

OFFICE USE ONLY

Receipt No. .................................................... Date ......................................