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

IADVL Member Name:
Surname First Name Father's/ Husband’s Name
     
Sex Age DOB Qualification
 
 
IADVL Member LM NO
State Branch of IADVL
 
Address
City
 
Pin Code
 
State
 
Tel No. - STD Code
Tel No. - Residence
 
Tel No.- Clinic
 
Mobile
Fax
Email
 
   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  
Address 2
Address 3