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

Name Beneficiary Member
 
Sex Age DOB Qualification
 
 
IADVL Member LM NO
DVL No
State Branch of IADVL
 
Enrollment Date To be contribute up to
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.
I enclose herewith Demand Draft / Cheque No. date drawn on for Rs. (RS ) Details of other mode of Payment_______________________________
Details of other mode of Payment
1. Admission Fees ( as per age)
2. Annual Membership Fees(Increment of Rs. 50/- every year) Rs. 750 (upto 31st March, 2025)
3. Advance Fraternity Contribution(AFC) Rs. 2,000/-
4. Legal Fees (optional/as per type of practice)
5. Advance Payment (optional)
  Indemnity
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.
Proposed By. Dr. LM No
Signature Of Nominee  
Signature (applicant)  
Signature Of proposer  
Address 2
Address 3