MEMBERSHIP FORM

ToThe Hon-Secretary

BLIND GRADUATES FORUM OF INDIA

Date Dear Sir/Madam

I am in agreement with the aims and objectives of BLIND GRADUATES FORUM OF INDIA and agree to abide by its rules and regulations made from time to time. Please enroll me as LIFE/ ORDINARY/ ASSOCIATE ORDINARY / INSTITUTIONAL MEMBER. My personal details are as following

Name - Address Present - Address Permanent - Address Office - Contact Phone No Residential (Both Landline and Mobile) Contact Phone No OfficeEmail ID - Date of Birth - Sex (Male / Female) - Nature of Blindness (Total/ Partial/ Colour/ Night) - Cause of Blindness - Age at which Blindness occurred -Any other illness or disability - Marital Status (Married/Unmarried/Divorced/Widowed) -Education (Please specify specialization also)Can you read and write Braille - Languages known - Special Skills, Aptitude, etc. - Presently Employed/ Self-Employed/ Unemployed - Nature of Occupation - Extra-curricular activities, hobbies, games, etc. - I am herewith sending a sum of Rs. as follows

Entrance Fee Rs 5

Life Membership Rs 100

Ordinary Membership Rs 10 (For year to year)

Associate Life Membership Rs 100

Associate Membership Rs 10 (For year to year)

(Tick the above options as applicable)

Total Rupees (in amount and words)

With Best Regards

Place and DateSignature of Applicant