DO NOT CHANGE SIZE WHILE COPYING OR PRINTING THIS FORM

This form can be used ONLY in Kerala.

Membership Form - Kerala PHOTO

Barcode

Instructions 1) Form should be preferably filled in English and in BLOCK CAPITAL LETTERS only 2) Attach photocopy of Photo ID proof & Age proof. Booth proof is also recommended. 3) Remit Membership fee of Rs 15 or Rs 5 for Women and SC/ST (attach photocopy of caste certificate). 4) The completeness of this form is the SOLE RESPONSIBILITY of the member. IYC will reject this form if any of the mandatory fields (Name, Date of Birth, Sex, Fathers Name, Booth No., Voter list Serial No., Assembly Name or Photograph) are missing, even if a barcode has been issued by the LRO.

iyc0110 8.4

Paste recent original photograph. Do not staple.

State : Lok Sabha : Assembly :

First Name

Mandalam :
Booth No. Voter list Serial No. :
Last Name

Please provide Booth Number & Voter list serial number as per Lok-Sabha Voter list 2009

Full Name :
Strike out whichever is not applicable

Father/Husbands Name :
D

Date of birth : Present Address :

Sex : M

Blood group :

City/District : Landline :
* Separate the STD code and number with a dash

Pincode : Mobile :
SC ST OBC Minority

Category : General

Profession : Email :

Declaration : I wish to apply for the annual membership of the Indian Youth Congress. I accept the constitution of the Indian Youth Congress and I declare that - The information given by me in this form and enclosures is true. - I am under 35 years of age and a Citizen of India. - I am not a member of any other political Party. - I have never been convicted of any criminal Thumb offences by any court

Signature / impression :
* Ensure signature / thumb impression is within the box
The membership fee paid along with the form is non-refundable under any circumstance

Date :
Acceptance of the membership form does not guarantee enrollment as a member of the Indian Youth Congress

Office use only :

Assembly code : Mandalam code : Received Rs. ________

Age Proof verified: Booth Proof verified:

Age Proof code : Booth No : LRO signature :

Date :

LRO name : ___________________________

You must produce this receipt during voting

Receipt

INDIAN YOUTH CONGRESS

#5 Raisina Road, New Delhi - 110001.

Barcode
Ensure that barcode sticker is pasted on the receipt.

(Strike out whichever is not applicable)

Name : Father / Husband Name :

Booth No :
*To be filled by LRO

Received Rs.________ Assembly code : *To be filled by LRO towards subscription

Pincode :
LRO signature :
Acceptance of this form does not guarantee enrollment into the IYC Incomplete forms even with bar codes axed will be rejected The membership fee is Performance non-refundable under any Management circumstance

Date :

LRO name :

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