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Special Patron Form

District State National International
1. Name:
Image:
2. Father / Husband Name:
3. Sex: Male Female
4. Residental Address:
5. Occupation:
6. Occupational Addres:
City:
District:
State:
Country:
7. Educational Qualification:
8. Date of Birth:
9. E-mail:
10. Phone Number:
11. Blood Group:
12. Marital Status: Yes No
13. Area Police Station Address:
14. Any Participation in Public Activities: Part Labour Union NGO
15. Do You Want to Donate?: Eyes Body Blood
16. Are You a Income Tax Assesse?: Yes No
If 'Yes' Write Your PAN No.:
17. Do You Get Any Benefit From State /
Central Government Welfare Scheme?		: Yes No
18. Do You Have Ration Card?: Yes No
19. Do You Have Voter's ID Card?: Yes No
20. Do you have Passport?: Yes No
21. Do you like to Participate in Self help Groups?: Yes No
22. Details of 'Human Rights Monthly Magazine' Magazine
'Subscription required'		: 1 Year 5 Year 10 Year 20 Year
Date
 Introducer Name
Verification Code* Audio Version Reload Image
Membership Details:

Domestic (only india)
Joint Membership : Rs. 1,500 (validity 3 years)
State Patron : Rs. 5000 (validity 2 years)
International
Joint Membership : Rs. 15,000 (validity 3 years)
State Patron : Rs. 30,000 (validity 2 years)