MEMBERSHIP FORM OF MADIPU CHARITABLE TRUST

S.No ................................................ Membership Code ................................

(To be filled in by office)

To,
The General Secretary,
Paste your
Madipu Charitable Trust
recent
Door No. 1,110 6 Meenadhi, Kinya,
Passport
Mangaluru, Dakshina kannada-575023, Karnataka, India.
Photograph
Sir, here

I ................................................................................................................................................................
s/o, w/o, d/o ..........................................................................................................................................................
want to apply for the membership of Madipu Charitable Trust.
NOTE: The duration of membership of member shall be 2 years.
MOBILE NO.
My Personal particulars are as follows:
1. Name .........................................................................................................................................................
2. Sex Male Female
3. Name of father/ husband ....................................................................................................................................
4. Age ................................................................ 5. Date of Birth.....................................................................
6. Educational qualification .............................................................................................................................
7. Address for Correspondance ............................................................................................................................
................................................................... ...................................
District ....................................................... State ................................... Pin Code ...........................
E-mail ID ..................................................................................................................................................
8. PAN No. ..............................................................................
11. Application received by (Name & ID No.) ................................................ Mobile
No...............................

Declaration
I hereby declare that I have carefully read the requisite form, In the event of violation of rules by me under any
circumstances, Madipu Charitable Trust is free to take any disciplinary action against me without any show-cause
notice, for which I shall be fully responsible. Please register me as a Member of Madipu Charitable Trust in
accordance with the rules of Madipu Charitable Trust.

Signature of Applicant