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[REGISTRATION FORM Receipt No.: EERE FUL THEFORMIN BLOCK CAPITALLETTERS “Oe aiels lame of Proposer Proposer 2010 (16 5%) Gender |_| Oxteot inh ase +t yo st avert acted tha 16 Sg 3 1 tan ao sad BO meta oom aang mith hs oom Address Pacose| | | | Mobile +91) || tii t Email 10 Resi No. ( uw ) Incase of Emergency Alternate Contact +91 [85.2 Lacs (Individual Cover) - Rs. 2,850/- (CJ Rs. 10 Lacs (Family Floater) — Rs. "28 300/- [J Rs. 2 Lacs (Family Floater) -Rs. 11,750/- [J Rs.5 Lacs (Family Floater) -Rs. 14,500/- (Premium includes 14.5% Service Tax) ‘sil famty members slo have tel personal I 10 (16 cg then please mention below j iS) HO10 No, Of avaliable) Nome ‘Relation M/F cos oe 2 Secu Dependent Children upto 25 years of age oma | oma STITT TTT TTT TT TTT oe Sam insured ef Personal Acdent plc is € V0 Lacs, €5 Lacs oF C2 Lacs {| PensowaL accioent roucy | "repos say ssp ak Suminned 7 Nominee Name: Gender: a p | Relation: Date of Birth: i + Demand Ort / Pay Orde shouldbe made n favor of “IRIMINTERNATIONAL ORGANISATION A/c Shravak Arogyam”Payable AT PAR or AT MUMBA cain renga NEF wi ret be acepte {Premium canalbobe pid ONE plete va ou mebate wont Bank Nome, Branch Name. Demand Orat/ Pay Order no: Amount: Dated FIEREEEIEEY have read and understood the terms & conditions reitedo the Phase ¢ mec Scheme | abi to folow them and accept all he changes / modifications / amenixner et I theres aed conditions of the scheme. alo hereby confi tht allthe details mentioned by me ae f correct and to the best of my knowledge, in all matters the decision of JO wil Be final T For more details please visit website httpy//www.jio.net.in ‘ain Intemational Organisation = 10's other SUPPORTING & CONNECTED Associations: Al Shemale Shika Members fa fur Sats, Active Volunteers ofan Sangh & Sama rom Al ver Ina Mahia Mond! & Yirak Mand, ‘Yak Mahasangh Jin CA Federation XAR, Jin Advocate Federation JAP, Jin interational Were Organsatclon NWO) Ji Intemational Yeuth Organon UO) [os Meds tava edocs ines ompatons and my ce Osun cat bes / Presa / ca serves ** J1O has the Right to TERMINATE (Reject) this application, if any details provided are inappropriate. rarer paicercoen Tamera Om

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