INDUSTRY4HER MEMBERSHIP FORM

#402, 4th Floor, Saleh Centre, 18, Cunningham Road,

Email:info@industry4her.com
Bangalore - 560052, India.
Phone:+91 80 22354455
MEMBERSHIP FORM
(Particulars must be filled by his/her own writing)
Form No. - Date:

Name of Applicant

Email-ID

Contact Number
Emergency Number

Local Address

Permanent Address

Academic Qualification: 12th Graduation Master PhD.

Technical Qualification :

Declaration: All above information filled

in form are true in my belief.

Candidate Signature

GUARDIAN CERTIFICATE

I certify that my ward has taken my permission to Declaration: All above information filled in form are
join above course and all future activities will be true in my belief.
under my acceptance.

Candidate Signature
Parent/Guardian Signature
GUARDIAN CERTIFICATE

I certify that my ward has taken my permission to join

above course and all future activities will be under my
acceptance.

Parent/Guardian Signature