ATAXIA AWARENESS CHARITABLE TRUST ®

                                    ATAXIA AWARENESS CHARITABLE TRUST ®

                  Registration No:E-5748 (Pune)

Office address: Kate Residency, Flat no 116 A, A wing, 4th floor, S.T Road, Dapodi, Pune – 411012.

 Maharashtra. INDIA. Contact – 020 27143184; +91 9730895840

MEMBERSHIP REQUISITION FORM

Please enroll me as (Tick the applicable box):

Volunteer

Regular Member

Patron Member

Supporter

My details are as follows(Please fill in CAPITAL letters):

Name – First …………………………………………………Last……………………………………………..

Date of Birth (Day/Month/Year)– ……………………………………………………………………………..

Address – …………………………………………………………………………………………………………

………………………………………………………………………………………………………………………

Tele/Mobile number/s – …………………………………………………………………………………………

Profession – ………………………………………………………………………………………………………

How I can help AACT – …………………………………………………………………………………………

………………………………………………………………………………………………………………………

………………………………………………………………………………………………………………………

…………………………………………………………………………

Signature of Applicant*

(*By signing you agree to abide by the ACCT charter of rules for members)

*******************************************************************************************************************

For office use only

Enrolled as……………………………………..

Signature of Managing Trustee

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