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NEW MEMBER REGISTRATION FORM
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Information about members
Surname
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First Name
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Father/Husband Name
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Gender
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Female
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Date of birth
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Age
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PAN Card No.
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Aadhar Card No.
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GST No.
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Disease 1
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Nominee Name
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Relation with nominee
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Nominee PAN Card No.
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Nominee Aadhar Card No.
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Information about spouse
Spouse Name
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Female
Date of birth
Age
PAN Card No.
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Aadhar Card No.
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GST No.
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Disease 1
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Contact information
Address 1
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Address 2
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Address 3/District
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City
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State
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ANDAMAN & NIKOBAR
ANDHRA PRADESH
ARUNACHAL PRADESH
ASSAM
BIHAR
CHANDIGARH
CHHATTISGARH
DELHI
GOA
GUJARAT
HARYANA
HIMACHAL PRADESH
JAMMU & KASHMIR
JHARKHAND
KARNATAKA
KERALA
LAKSHADWEEP
MADHYA PRADESH
MAHARASTRA
MANIPUR
MEGHALAYA
MIZORAM
NAGALAND
ORISSA
PONDICHERRY
PUNJAB
RAJASTHAN
SIKKIM
TAMIL NADU
TELANGANA
TRIPURA
DAMAN AND DIU
UTTAR PRADESH
UTTARAKHAND
DADRA AND NAGAR HAVELI
WEST BENGAL
ANDHRA PRADESH (NEW)
LADAKH
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PinCode
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Other Details
IMA LM No.
GUJ No.
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Qualification
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Mobile 1
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Mobile 2
Email
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Password
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Upload Member's Documents Here (.jpg format and size must be in 100kb to 400kb)
Aadhar card
PAN card
LMC Certificate
Birth Certificate