Registration Form
Personnel Information
Name of the Applicant: _________________________________________________________________________
Beneficiary Name :_____________________________________________________________________________
Father’s / Husband Name:_______________________________________________________________________
Date of Birth : _____________________ Occupation : _______________________ Gender : Male ( ) / Female ( )
Phone : ___________________________ Mobile : _______________________ Pan No. : ___________________
Email : ________________________________________
Address Information
Address : ___________________________________________________________________________________
____________________________________________________________________________________________
Post / PS. : _____________________ City : _______________________ District : ________________________
State : _________________________ Pin code : _______________________
Account Information
Bank Name : _______________________________________Branch Name : _____________________________
Account No : __________________________ IFSC Code : _____________________ ECS : ECS ( ) / Non ECS ( )
Nominee Information
Nominee Name : _____________________________________ Relation : _________________ Age : _________
Sponsor Details
Name of Sponsor : _____________________________________________________________________________
Contact No. : _____________________ Sponsor ID : __________________________ Position : Left ( ) / Right ( )
New Member ID : _____________________________
All Payments to be made in favor of __________________ Account No. _____________ .
Have read and agreed to the terms & Conditions written overleaf to be a purchaser. I also declare that all the
above information filled above is true of the best of my knowledge and I am purchasing this product with my
own decision.
Note:
Any Claims / Refund should be within 30 days from the date of joining / registration.
The Membership / Registration is non transferable.
Any Membership / Registration on a single person name cannot exceed more than three.
All Forms should be submitted dully filled & signed with a passport size photograph affixed.
For any further queries kindly contact Office between 9.00 am to 6.00 pm Monday to Friday.
Signature_________________
Office : “DIDC”, G-13, NANO, Haware Fantasia Business Park, Next to Inorbit Mall, Sector 30,
Nr. Vashi Station, Vashi, Navi Mumbai.
Registration Form
Personnel Information
Name of the Applicant: _________________________________________________________________________
Beneficiary Name :_____________________________________________________________________________
Father’s / Husband Name:_______________________________________________________________________
Date of Birth : _____________________ Occupation : _______________________ Gender : Male ( ) / Female ( )
Phone : ___________________________ Mobile : _______________________ Pan No. : ___________________
Email : ________________________________________
Address Information
Address : ___________________________________________________________________________________
____________________________________________________________________________________________
Post / PS. : _____________________ City : _______________________ District : ________________________
State : _________________________ Pin code : _______________________
Account Information
Bank Name : _______________________________________Branch Name : _____________________________
Account No : __________________________ IFSC Code : _____________________ ECS : ECS ( ) / Non ECS ( )
Nominee Information
Nominee Name : _____________________________________ Relation : _________________ Age : _________
Sponsor Details
Name of Sponsor : _____________________________________________________________________________
Contact No. : _____________________ Sponsor ID : __________________________ Position : Left ( ) / Right ( )
New Member ID : _____________________________
All Payments to be made in favor of __________________ Account No. _____________ .
Have read and agreed to the terms & Conditions written overleaf to be a purchaser. I also declare that all the
above information filled above is true of the best of my knowledge and I am purchasing this product with my
own decision.
Note:
Any Claims / Refund should be within 30 days from the date of joining / registration.
The Membership / Registration is non transferable.
Any Membership / Registration on a single person name cannot exceed more than three.
All Forms should be submitted dully filled & signed with a passport size photograph affixed.
For any further queries kindly contact Office between 9.00 am to 6.00 pm Monday to Friday.
Signature_________________
Office : “DIDC”, G-13, NANO, Haware Fantasia Business Park, Next to Inorbit Mall, Sector 30,
Nr. Vashi Station, Vashi, Navi Mumbai.