Membership Form

BORI DEVELOPMENT TRUST

House no. 197, Durganagar, Bori, Goa 403401

Application to become lifetime member

To the Settlor

I______________________ wish to be a lifetime member of Bori Development Trust, as I am :

□ Born in Bori

□ Present resident of Bori

□ Ancestoral origin from Bori

□ Devotee of Navdurga temple

My details are as follows:

Full Name______________________________ Father/Husband of ____________________________________

Age ________ Marital Status___________________

Full Address_____________________________________________________________________

Tel: ____________________ Mobile:____________________ Email:________________________________

I shall abide to the rules and regulations of Bori Development Trust which I have read and understood.

Please accept Rs 1000 towards Life Membership Registration Fees vide cash/DD/Cheque no. _______ bank ____________________

Yours faithfully,

__________________________________________________________________________________________________________________________________________________________

FOR OFFICIAL USE ONLY:

Mr./Mrs/Ms ____________________________________________________ is accepted as Lifetime Member. The registration fees received under receipt no_____________

Dtd.__________________

SETTLOR