Name Email* Phone/Mobile Address Father/Husband Name Date of Birth Age Name of Spouse Spouse Date of Birth What was your assignment prior to retirement What is your present assignment? Briefly describe about your educational, technical and/or business qualifications, your expertise and experience etc. Caste Give details of your dear ones including your spouse, whom to contact in cases of emergency (Name, Age, Contact nos, Email id, Relation with applicant) Select the type of membership Distinguished Membership - Rs. 5000.00 Life Membership - Rs. 1500.00 Distinguished Membership of Spouse - Rs. 1000.00 Life Membership of Spouse - Rs. 500.00 Life-time contribution for quarterly magazine “Bhavana Sandesh” - Rs. 1000.00 (mandatory) DETAILS OF PAYMENT Mode of payment Cash DD Cheque Amount in figure: Details of Cheque/DD