SAMYAK THEATER NAGPUR
SAMYAK PARIVAR REGISTRATION FORM
* Required
FULL NAME
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Your answer
AGE
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Your answer
DATE OF BIRTH
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MM
/
DD
/
YYYY
GENDER
*
MALE
FEMALE
ADDRESS
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Your answer
STATE
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Your answer
CONTACT DETAIL
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Your answer
EMAIL ID
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Your answer
CO-APPLICANT NAME
*
Your answer
OCCUPATION / JOB
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Your answer
FULL DETAILS OCCUPATION / JOB ADDRESS WITH CONTACT DETAILS
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Your answer
EDUCATION DETAIL
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Your answer
REGISTRATION FEES
*
YEARLY (Rs. 500/-)
5 YEARS (Rs. 2000/-)
DONATION
DONATE DIRECTLY
Account Name: Samyak Theater
Account No: 0500000100289450
Bank & Branch: Punjab National Bank - Indora Chowk, Nagpur-440017
IFSC Code: PUNB0050000
Account Type: Savings
I AGREE TO REGISTER AS A MEMBER OF SAMYAK THEATER, NAGPUR
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