WNHO HEALTH CARE PVT.LTD.(Health & Wealth Business Forum-Club)
LIFE MEMBERSHIP FORM
Please fill this form CORRECTLY with* is COMPULSORY
A. INTRODUCER DETAILS
FULL NAME(AS PANCARD) : …………………………………………………………………………………….................................... USER ID* : ……………………………………… MOBILE NO*/ EMAIL ………………………………………………
B PERSONAL DETAILS
NAME* & Photo : ……………………………………………………………………………………………………………………..
GENDER : MALE/FEMAL MARITAL STATUS: SINGLE/MARRIED/OTHER
DATE OF BIRTH* (DD/MM/YYYY) NATIONALITY : ………………………………………………………
STATUS : RESIDENT INDIVIDUAL/NON RESIDENT/FOREIGN NATIONAL
PAN NUMBER* : (PLEASE ATTACHED SELF ATTESTEDBCOPY OF PANCARD) PREFERRED USERNAME*: 1 2 3
EMAIL ADDRESS* : ……………………………………………………………………………………………………………………… MOBILE NUMBER* : …………………………………….
C ADDRESS DETAILS (PLEASE ATTACH SELF ATTESTED COPY OF ADDRESS PROOF,LICENCE, PASSFORT, BILLS ETC)
RESIDENT ADDRESS : ………………………………………………………………………………………………………………………….
CITY/TOWN : ………………………………………………… PIN CODE : …………………………………………………..
STATE : ………………………………………………… COUNTRY : …………………………………………….. PERMANENT ADDRESS IF DIFFERENT FROM ABOVE
PERMANENT ADDRESS : ……………………………………………………………………………………………………………………………
CITY/TOWN : ………………………………………………… PIN CODE : …………………………………………………..
STATE : ………………………………………………… COUNTRY : ……………………………………………………….
D. BANK DETAILS (PLEASE ATTACH SELF ATTESTED COPY OF BANK ACCOUNT DETAILS)
ACCOUNT HOLDER NAME : ……………………………………………………………………………………………………………………….
BANK NAME : …………………………………………………………………………………………………………………………………………
ACCOUNT NUMBER : ……………………………………………………… ACCOUNT TYPE : SAVING/CURRENT
BRANCH NAME : …………………………………………………………….. IFSC CODE : ……………………………………………
Declaration: I hereby declare that the details furnished above are true and correct to the best of my knowledge and belief and I undertake to inform you of any changes therein, immediately. In case any of the above information is found to be false or untrue or misleading or misrepresenting, I am aware that I may be held liable for it. I hereby acknowledge that I have reviewed and understand this WNHO Health Care Ptv.Ltd application and agreement including all of the document defined herein as “materials” which are incorporated herein, and that I agree to be bind by all of them.
………………………………………………….. signature of the applicant date…………………………..(dd/mm/yyyy) For office use only originals verified and self-attested document copies received(yes/no)
Name: signature: company stamp:
LIFE MEMBERSHIP FORM
Please fill this form CORRECTLY with* is COMPULSORY
A. INTRODUCER DETAILS
FULL NAME(AS PANCARD) : …………………………………………………………………………………….................................... USER ID* : ……………………………………… MOBILE NO*/ EMAIL ………………………………………………
B PERSONAL DETAILS
NAME* & Photo : ……………………………………………………………………………………………………………………..
GENDER : MALE/FEMAL MARITAL STATUS: SINGLE/MARRIED/OTHER
DATE OF BIRTH* (DD/MM/YYYY) NATIONALITY : ………………………………………………………
STATUS : RESIDENT INDIVIDUAL/NON RESIDENT/FOREIGN NATIONAL
PAN NUMBER* : (PLEASE ATTACHED SELF ATTESTEDBCOPY OF PANCARD) PREFERRED USERNAME*: 1 2 3
EMAIL ADDRESS* : ……………………………………………………………………………………………………………………… MOBILE NUMBER* : …………………………………….
C ADDRESS DETAILS (PLEASE ATTACH SELF ATTESTED COPY OF ADDRESS PROOF,LICENCE, PASSFORT, BILLS ETC)
RESIDENT ADDRESS : ………………………………………………………………………………………………………………………….
CITY/TOWN : ………………………………………………… PIN CODE : …………………………………………………..
STATE : ………………………………………………… COUNTRY : …………………………………………….. PERMANENT ADDRESS IF DIFFERENT FROM ABOVE
PERMANENT ADDRESS : ……………………………………………………………………………………………………………………………
CITY/TOWN : ………………………………………………… PIN CODE : …………………………………………………..
STATE : ………………………………………………… COUNTRY : ……………………………………………………….
D. BANK DETAILS (PLEASE ATTACH SELF ATTESTED COPY OF BANK ACCOUNT DETAILS)
ACCOUNT HOLDER NAME : ……………………………………………………………………………………………………………………….
BANK NAME : …………………………………………………………………………………………………………………………………………
ACCOUNT NUMBER : ……………………………………………………… ACCOUNT TYPE : SAVING/CURRENT
BRANCH NAME : …………………………………………………………….. IFSC CODE : ……………………………………………
Declaration: I hereby declare that the details furnished above are true and correct to the best of my knowledge and belief and I undertake to inform you of any changes therein, immediately. In case any of the above information is found to be false or untrue or misleading or misrepresenting, I am aware that I may be held liable for it. I hereby acknowledge that I have reviewed and understand this WNHO Health Care Ptv.Ltd application and agreement including all of the document defined herein as “materials” which are incorporated herein, and that I agree to be bind by all of them.
………………………………………………….. signature of the applicant date…………………………..(dd/mm/yyyy) For office use only originals verified and self-attested document copies received(yes/no)
Name: signature: company stamp:
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