INTERNATIONAL HUMAN RIGHTS ASSOCIATION

(An N.G.O. for the Service of Humanity) Reg. No. 89/IV/2012, Reg. Office: Muzhayil Buildings,
Lalam Jn.,Petta Road, Pala P.O., Kerala State, India, Pin: 686575,Mob:9495965777,9447463876
Web Site:www.humanrightsvision.org, Facebook.com/onlinehumanrightsEmail.humanrightsvision@gmail.com
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APPLICATION FOR MEMBERSHIP IN IHRA FORM

To be filled in by capital letters Serial No …………………

1.Name……………………………………………………………………………………………
2.Name of parent/Spouse…………………………………………………………………………
3.Date of birth……………………… 4.Age………….5.M/F………. 6.Blood Group…………
7. Address………………………………………………………………................................................
…………………………………………………………………………………………...……………………………
……………………………………………………………………………………………8.Pin…….......................
9.Educational qualification ………………………..……..10.Profession……..…………………….......................
11.Panchayath /Municipality ………………………………12.Village ……..……………………………………
13.Taluk………………………………14.District………………………..................15.State……………….…….
16.PAN/GIR/AADHAR No…………………………………17.Voters ID Card No ………...................................
18.Phone No (R)…………………………………19.Mobile No ……………………………………………….......
20.E-Mail ID…………………………………………………………….....21.Website.............................................
22. Facebook.com......................................................................................................................................................
DECLARATION

I, ------------------------------ ---------------------------hereby declare that the particulars given above are true to the best of my knowledge and belief
.1 will abide by the rules and regulations of the forum of International Human Rights Association (IHRA) and will serve the humanity to the best of
my ability without any profit motive. I will conduct myself with the highest ethics and integrity. I hereby unconditionally agree to publish my name
with or without photograph in the mass media. I also affirm that I will resign, without any hesitation or complaint, whatsoever, from any post with
the forum I may be holding in due course, in the event I will be asked by the higher committee/ committees of the forum to do so. I also understand
that a member of the forum must honor the bylaw of the forum and must gladly do the duties entrusted and accepted by him/her. I hereby solemnly
pledge and agree to function in accordance with the existing by-law of the forum, which may be updated from time to time. I am also liable to abide
by the laws of my mother land and the directions of the United Nations with regard to the Human Rights. I know that I must have a clean record of
exemplary character and there will not be any legal case against me either with the police or in any judicial court. I understand that I must not be a
member/an associate /well-wisher of any extremist group. I also know that a member of the forum must not hold any responsible position of any
political party, trade union, any other Human Rights Organization and/or religious organization. I understand that membership is given to me for a
period of one year from the date of joining and it can be renewed yearly, as per the existing rules. I also understand that the forum reserves all rights
to accept/reject this application. In case of any dispute it can be taken up only with a court of Justice in Pala, Kottayam Dist., Kerala State. I am
desirous to serve the public without any selfish motive and without any reward. And I affirm that if there will be any omission and fault on my part, I
shall be solely responsible for it and that I will accept whole heartedly any decision taken by the forum. In case of necessity in future, to produce
police verification certificate about my character, I will promptly obtain and submit the same for renewal of my membership.

Place :
Date : Signature of the applicant

RECOMMENDATION CERTIFICATE

I, -----------------------------------------------------------------------ID No------------------------------------------------------------recommend Sri, --

-------------------------------------------------------------------to become a member of this forum. I know him personally for the last five
years and I am satisfied with the identity of the party on the basis of my independent enquiry. I hereby declare that the foregoing
statements are true and correct to the best of my knowledge and belief. I am responsible for this person’s conduct and behaviour.

Place :
Date : Signature of Introducer
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PAYMENT MODE: The Canara bank Ltd Ponkunnam Branch. Account No. 2 6 8 4 2 0 1 0 0 0 1 3 1,
IFSC No. CNRB0002684. Cash Rs……………Bank ref. No………………….………………..……….Date……………
N.B: Please Submit 2 Passport size photos , Copy of any Identity card issued by Government and Police Verification
Certificate.

For office use only

Recommended & forwarded for approval

President /Secretary President /Secretary President /Secretary President /Secretary

(Panchayat committee) (Taluk committee) (District committee) (State committee)

ID No: IND/-----------------------------------------------------------------Effective Since---------------- Validity to be renewed on ---------------

APPROVED / REJECTED

Date: Chairman / Secretary