User Application Form

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MAHELIKHA SWASTHYA JAGRUKTA FOUNDATION

Registration Form

Name * :

Gender * :

Date of Birth * :

Profession:

Blood Group *:

State * :

District *:

Mobile No. *:

Aadhar No. *:

Address *:

Pin Code *:

Email:

Profile Picture:

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Other Document

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Registration Fee - 200/-

Bank Detail -

BANK NAME - CENTRAL BANK OF INDIA
ACCOUNT NO - 5688815528
IFSC CODE - CBIN0283071
BRANCH - KOTMA

UPI SCAN:

Payment Mode *:

Payment Receipt Upload:

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