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LENSFED

Licensed Engineers& Supervisors Federation


Reg.No. : 09-5/98
Kerala State Committee
Lensfed Bhavan,Lenin Nagar,Bakery Jn.,Thiruvananthapuram,Phone: 04712335688

MEMBERSHIP REGISTRATION FORM


Date :

Year of License Obtained : Photo

District :

Taluk/Area* :

Unit* :

Name in Block Letters * :

Residential Address * :

Pin* :

Land Phone-Res * :

Official Address/Address for Communication * :

Pin * :

Land Phone * :

Moboile Phone * 1 :
2 :

E-Mail * 1 :
2 :
Date of Birth * :

Age :

Blood Group :

Sex : Male/Female
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Category License Obtained * :

License No * :

Date of Issue * :

Next Date of Renewal* :

Academic Qualification * 1 :

2 :

Technical Qualification * 1 :

2 :

Membership in Other Organizations :

Martial Status * :

Other Professional Activities/Business :

Hobby :

DECLARATION

I,...........................................................hereby drclare that the particulars furnished

above are true and correct.

Yours Faithfully,

Name & Signature

Place :

Date :

Note : * Mandatory Field.

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