INDIA 1112 Khan Abdul Gaffar Khan Road Worli Seaface Mumbai 400 030 M P SHAH ALL INDIA TALKING BOOK CENTRE Tel No 66838686 Extension No 239 Direct no 66838639 E mail talkingbook ID: 341450
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NATIONAL ASSOCIATION FOR THE BLIND (INDIA) 11/12, Khan Abdul Gaffar Khan Road, Worli Seaface, Mumbai - 400 030 M. P. SHAH ALL INDIA TALKING BOOK CENTRE Tel. No. 66838686 (Extension No. 239) Direct no. 66838639 E - mail: talkingbook@nabindia.info ----------------------------------------------------------------------------------------------------------------------------- ----------------- APPLICATIO N FORM FOR MEMBERSHIP TO BE DULY FILLED UP AND RETURNED TO THE NAB M. P. SHAH ALL INDIA TALKING BOOK CENTRE. -------------- --------------------------------------- ---------------------------------------------------------------------------- ------------- DATE OF APPLICATION : _ ______________ _____ __ _ DATE OF ISSUE : _ __________ __________ _ _ FOR OFFICE USE ONLY MEMBERSHIP NO. : _________ ______________ 1. NAME : ______ _________________________________________________________________________________ ______________ _______ _ __ _ _ 2. ADDRESS : ____________________________ _ __ _ ____________________________________________________________________________ _ _____________________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________________ 3. E. MAIL ADDRESS : ___ __ _______________________________________________________________________________________________ 4. TEL.NO. & MOBILE NO. : ___ __________________________________________________________ ____________ _____________________ 5. DAT E OF BIRTH : ___ _ __________________________________________________________________________________________________ 6. OCCUPATION : _____ ________ ___________________________________________________________________________________________ 7 . NAME OF SCHOOL/COLLEGE & STANDARD (IF STUDENT) : _____________________ _______________________ _____ __ __ _ _____________________________________________________________________________________________________________________________ 8. NAME OF THE EMPLOYER ( IF WORKING ): ______________________ __ ________________________________________________ 9 . WOULD LIKE TO RECEIV E THE RECORDED CDs IN THE FOLLOWING LANGUAGE/S ( KINDL Y TICK YOUR CHOICE/S ) : ENGLISH / HINDI / MARATHI / GUJARATI 10. ADMISSION FEE, ANNUAL / LIFE MEMBERSHIP FEE & DEPOSIT AMOUNT SENT VIDE : 1 . Money Order a. E MOPNR No. : ______________________________ b . Date : ____________________________ __ c . Amount : ____________________________ __ 2. Cheque / Demand Draft a. No. : ____________________________ __ b. Date : ____________________________ __ c. Amoun t : ____________________________ __ 3. Online Payme nt a. Unique Reference No: : ____________________________ __ b . Date : ____________________________ __ c. Amount : ____________________________ __ ---------------------------------------------------------------------------------------------------------------- --------- _______________ __________________ ______________________ SIGNATURE / TH UMB IMPRESSION / SEAL OF THE INSTITUTION