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MEMBERSHIP FORM

CATEGORY OF MEMBERSHIP
MEMBER/NOMINEE NAME
SURNAME
DATE OF BIRTH (dd/mm/yyyy)
NATIONALITY
MARITAL STATUS
DATE OF WEDDING ANNIVERSERY
PASSPORT NO.
ISSUING AUTHORITY
RESIDENTIAL ADDRESS
TEL
FAX
EMAIL

SPOUSE

NAME
DATE OF BIRTH 
NATIONALITY
PASSPORT NO.
I.T.PAN NO

BUSINESS DETAILS

NAME OF COMPANY
NATURE OF BUSSINESS
DESIGNATION
BUSINESS ADDRESS
TEL
FAX
EMAIL

CHILDREN DETAILS

NAME   
D.O.B
Male
Female


Payment

Full payment based on category applied for to accompany Membership Form

Dependant Card to

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Terms & Condition of Membership and Rules of L'AMICALE
As A Member/Corporate designee, I agree to comply with and be bound by the terms & condition of Membership and rules of L'AMICALE as the same may from time to time be in force.
I Accept