Applay

Category of Membership applying for :

Two Copies
P.P. Size
Photographs of
Applicant.

Section A : Your Personal Information

1. Applicant's Full Name :

2. Father's Name :

2. Mother's Name :

3. Date of Birth :

4. Nationality :

5. Blood Group :

6. Passport / N.I.D No :

7. TIN :

8. Marital Status : Married Unmarried Widow Widower

Spouse Name :

9. Is your spouse a career person ? If so, please furnish details.

10. Children's Name & Date of Birth :

One Copy
P.P. Size
Photograph of
Applicant's Spouse
& Children

Section B : Information about Your Educational & Professional Qualification

1. Highest Academic Achievement : HSC/ A-Level Graduation Post Graduation

Field of Education :

Educational Institution :

2. Current Position :

Company Name :

Year of Commencement :

Address :

Website :

3. Annual Income (As furnished to Tax Authorities during last financial year) :

Section C : Information about your Residence

1. Present Address :

2. Permanent Address :

Section D : Information to Contact You

1. Work Phone :

2. Home Phone :

3. Cell :

4. Email (Work) :

5. Email (Personal) :

I prefer to receive Letters, Circulars & Bills from the Club at my :

(a) Mailing Address Present Address Permanent Address Work Address

(b) Email Address Email (Work) Email (Personal) Both

Section E : Miscellaneous

1. Why are you interested to become a member of Purbachal Club ?

2. Membership of any other Club etc (if any) :

3. Your area of interest in Club activities : Indoor Sports Outdoor Sports Social Activities Cultural Activities

4. Name and signature of proposer & seconder :

(a) Name of Proposer Club A/c. No. : Signature :

(b) Name of Seconder Club A/c. No. : Signature :

Name of at least two friends or acquaintances other than proposer & seconder amongst existing Permanent, Life and Donor Members of Purbachal Club who may be referred to regarding your eligibility.

Name : Club A/C. No. :

5. Nominee (Optional) :

(In case of your demise, you may nominate one eligible person from amongst your Spouse / Children / Grand Children for consideration of awarding your membership.)

Name :

Relationship :

6. Any other information you wish to furnish in support of your application :

I hereby declare that the information provided above is true to the best of my knowledge. I understand that any false and untrue declaration will make my application liable to cancellation and may result in expulsion from the Club even after my election as member.

I hereby acknowledge that I have read and accepted the Memorandum and Articles of Association of Purbachal Club Ltd.

I hereby forfeit my right to challenge through legal or other means any part of the Memorandum and Articles of Association.

Date :

(Signature of Candidate)

Purbachal Club Limited

APPLICATION FORM FOR MEMBERSHIP OF THE CLUB