Online Membership Form

Dacorum Indian Society Membership Application Form Year 2018

Form to be completed by the principle Adult applicant

(* denotes mandatory fields).

SECTION 1*

PLEASE COMPLETE THE FORM AND SUBMIT AT THE END.

Title:*
First Name:*
Surname:*
Gender:*
Address Line 1:*
Address Line 2:
Town/City:*
County:*
Post Code:*
Home Tel. No.:
-
Mobile No.:*
E-mail:*
E-mail confirmation:*
Profession:
Preferred method of communication You can contact us anytime to be removed or change this:*
Add phone no. to DIS WhatsApp group?:*
SECTION 2. Fill this section if you have additional adults to register otherwise scroll down to section 3.
Enter other adults living at the above address. Max four. Any more please email dis.hemel@gmail.com
First Adult...

Title1:
First Name1:
Surname1:
Gender1:
E-mail1:
Profession1:
Mobile No.1:
Would you like to receieve DIS Email?1:
Add phone no. to DIS WhatsApp group?1:
Second Adult..
Title2:
First Name2:
Surname2:
Gender2:
E-mail2:
Profession2:
Mobile No.2:
Would you like to receieve DIS Email?2:
Add phone no. to DIS WhatsApp group?2:
Third Adult...
Title3:
First Name3:
Surname3:
Gender3:
E-mail3:
Profession3:
Mobile No.3:
Would you like to receieve DIS Email?3:
Add phone no. to DIS WhatsApp group?3:
Fourth Adult...
Title4:
First Name4:
Surname4:
Gender4:
E-mail4:
Profession4:
Mobile No.4:
Would you like to receieve DIS Email?4:
Add phone no. to DIS WhatsApp group?4:
SECTION 3 Fill this is you have any children to register else scroll down to section 4.
Children (under 18 years of age) living at the above address.
First Child...
First NameC1:
SurnameC1:
GenderC1:
Date of birthC1:
child's interestsC1:
Second Child..else scroll down to section 4.
First NameC2:
SurnameC2:
GenderC2:
Date of birthC2:
child's interestsC2:
Third Child...else scroll down to section 4.
First NameC3:
SurnameC3:
GenderC3:
Date of birthC3:
child's interestsC3:
Fourth Child...else scroll down to section 4.
First NameC4:
SurnameC4:
GenderC4:
Date of birthC4:
child's interestsC4:
SECTION 4 *
Terms & Conditions. PLEASE READ...and after scroll to section 5
TERMS & CONDITIONS:
SECTION 5*. Fee & Payment options.
Membership Fee:*
Payment method:*
Principle applicant's signature :*
Date:
SECTION 6*. SUBMIT. FINAL PART. Please check all mandatory fields are filled in.