REGD NO : DR/GGN/179 (2008-09)

LIFE MEMBERSHIP FORM

(Officer Rs 500, JCOs – Rs, 200, OR – Rs.100)

To,

The General Secretary

Indian Ex Servicemen Movement

543, Sector 23, Gurgaon – 122017, Haryana

1. No…………………..Rank……………….. Name…………………………………………….

S/o……………………Date of Birth……………….Next of Kin………………………………

Present Address…………………………………………………………………………………..

Tele No……………………………………… Email ID…………………………………………

2. Unit/Service/Corps…………………………………Date of Retirement………………………..

PPO No./discharge Book No……………………………………………………………………..

3. I certify that above information is true and correct to the best of my knowledge. I also hereby undertake to abide by the IESM constitution if enrolled as member.

Date………………………. Signature of the Applicant

Enclosures_ Check/draft No……………………dated…………..drawn on ……………………..for Rs 500/200/100 (delete whichever not applicable) …………………………………………………………………………………………………………….

RECEIPT-CUM ACKNOWLEDGEMENT

Received a sum of Rs………………………by cheque/draft/IPO/cash/ Form

No……………….Rank……………Name……………………………………………………..

………………………………….with thanks on account of IESM Life Membership Fee.

Signature and Stamp Recipient