BHARAT SWABHIMAN (TRUST)

Form for Special Member

Administrative Office : Patanjali Yogpeeth, Maharshi Dayanand Gram, Bahadrabad, Haridwar-249402,
Uttarakhand, India
Phone No. : 01334-240008, 244107, 246737 Fax No. : 01334-244805, 240664

Cell I.D. No.

(To Be Filled By Office)

1. Name of Applicant ........................................................................................................................................

2. Father's/ Husband Name ...............................................................................................................................
3. Date of Birth .......................................................................................................... Age .................................
4. Gender : Male
Female

5. Weight ............................................................................................................................................................
Are you suffering from any chronic disease. Yes
No

6. Contact Address .............................................................................................................................................
.................................................................................... Block ............................... Tehsil ...............................
Town ............................... District ............................... State.............................. Pin Code ...........................
7. Telephone No./ Mobile (Residence) ....................................................... Office ............................................
8. E-mail I.D. .......................................................................................................................................................
9. Educational Qualification ................................................................. 10. Monthly Income..............................
11. Present Occupation
Agriculture
Business
Service
Others

12. Are you Member of Patanjali Yogpeeth? If yes, Please quote your Membership Code or Receipt No.
........................................................................................................................................................................
13. Are you a Yog Teacher of Patanjali Yogpeeth? If yes, Please quote your Yog Teacher I.D. or Receipt No.
........................................................................................................................................................................
14. Are you ready to contribute 10% of your time to this Organisation? Yes
No

15. Are you abide by seven Principles & seven Codes of Conduct? Yes
No

16. Are you prepared to donate 1 to 10 percent of your income to the Organisation for building of new India?
Yes
No

17. Detail of Donation
a. Cash

b. Demand Draft

D.D. No. ................................... Amount ................................... Bank Name ......................................
18. To which Cell of Bharat Swabhiman (Trust), you like to associate? ..............................................................
Name of Receiver of Application form ............................................................................................................
Yog Teacher's I.D. No. ............................................................ Mobile No. ................................................
Declaration
I have read five Paroles, seven Principles, seven Codes of Conduct and Brief Norms of Bharat Swabhiman
(Trust) mentioned overleaf. I pledge that I will abide by them.

Applicant's Signature