13th Annual General body meeting on 23-2-2024 at Hyderabad.

Please fill up the form, Payment Link will be sent by office.

Registered Office

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

Enrollment Form

First Name
Middle Name
Last Name
Beneficiary Member
Sex
DOB (MM/dd/yyyy)
Age  
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
Email
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.
 
further agree to abide by the conditions down in the constitution approved by the General Body for this Trust.
 
Details of other mode of Payment
1. Admission Fees ( as per age) Rs.
2. Annual Membership Fees(Increment of Rs. 50/- every year) Rs.
3. Advance Fraternity Contribution(AFC) Rs.
4. Legal Fees (optional/as per type of practice)
Rs.
5. Advance Payment (optional) Rs.
Total Fees Rs.3250.00
Full Name of the Nominee
If nominee is minor, DOB (MM/DD/YYYY)
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   [JPG,JPEG,PNG Only]
Signature (applicant)   [JPG,JPEG,PNG Only]
Note: Payment Link will be sent by office.
Address 2
Address 3
Enrollment Date (MM/dd/yyyy) To be contribute up to