Please fill up the form, take a print of it & send along with DD / Cheque at par to the following address :

Registered Office

DVL Welfare Trust
Shreeji Chambers, Brahmpuri
Dandia Bazar,
Vadodara - 390001
Gujarat, India.

Enrollment Form


First Name Middle Name Last Name
     
Gender DOB Age LMNo
 
Qualification State Branch of IADVL
   
     
In case of Beneficiary Member Fill 1.,2.,& 3
 
Address
 
City
 
Fax
 
 
Tel No. - Residence
   
Address 2
Pin Code
 
Tel No.- Clinic
   
Email
 
Address 3
State
 
Mobile
 
 
 
   I hereby declare that the above information is true and I have withheld no information whatever in the Application, and I agree to pay the amount demanded.
   I further agree to abide by the conditions down in the constitution approved by the General Body for this Trust.
     
Full Name of the Nominee If nominee is minor, DOB
 
Name of Nominee/Guardian with name in case of minor Relationship with applicant
   
Address of Nominee
 
Proposed By. Dr.
 
Proposer Name
 
Signature