Kerala Catholic Bible Society

KERALA CATHOLIC BIBLE SOCIETY

REF NO. E.R.649/91
PASTORAL ORIENTATION CENTRE
PB No.2251, PALARIVATTOM, KOCHI, KERALA, INDIA. PIN: 682 025,
Phone: +91 484 280 5897, 280 5722, 280 5815 Fax: +91 484 280 5897
web: http://www.keralabiblesociety.com email: secretary@keralabiblesociety.com

APPLICATION FOR MEMBERSHIP
* indicates required fields
Printable Form

1	Name of the Applicant: *
2	Category:*	Individual Institution Association Parish
3	Permanent Address with Pin code: *
4	Phone Number with STD Code:
5	Mobile Number:
6	Email Address:
7	Diocese:*
8	Parish:*
9	Address for correspondence:*
	If An Individual *
10	Male/Female	Male Female
11	Date of birth & Age:	(dd/mm/yyyy) yrs
12	Father/Husband's Name:
13	Your Passport Photo (required if you need an ID card with photograph)
	If Not An Individual *
14	Name of the Authorised Person:
15	Designation:

16	Type of Membership:*	View Types of Membership and Fee Structure Payment Methods
17	Amount and Method of remittance:*

	PLEDGE I hereby pledge that as I receive the Membership, I will be abiding by the rules and regulations of the Society and work for the benefits of the Society Signature of the Applicant (sign by Checking above check box)
	Place:*
	Date:*
FOR OFFICE USE
18	Date of Membership:
19	Receipt No:	Secretary	Chairman
20	Membership Register no: