Noakhali Zila Samity | Apply Member

Central Office : Address: G-2, Rupayan Taj, 1,1/1, Naya Paltan, Dhaka-1000

Established : 1905, Reg. No- D-1971/1986

Contact : +880 2226-666080, E-mail: noakhalizilasamitydhaka@gmail.com, Web: demo.noakhalizillasamitydhaka.com

No-

Date :

Life member fee-Tk. 15,000/- (Fifteen Thousand) only, payable through pay order/bank. Price of this form: Tk. 100/- (One Hundred) only.

Part 1 : (Applicant's Information)

To,

The President/General Secretary

Noakhali Zila Samity, Central Committee, Dhaka.

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Dear Sir,
I am interested in becoming a life member of Noakhali Zila Samity, Dhaka. The necessary information is furnished below-

1. Name :

Nominee's Name :

2. Father's/Husband's Name :

Mother's Name :

3. Present Address :

4. Permanent Address : Village

Union Name :

Post Office :

Upazila :

District :

5. Profession :

Religion :

Date of Birth :

6. National ID No :

Blood Group :

7. Contact : Mobile Phone No :

E-mail :

8. Pay Order/Deposit Slip No- :

9. Bank Account: Account Name Noakhali Zila Samity Dhaka, Account No : 16014030000015, Sonali Bank PLC, NCTB Branch, Dhaka.

10. Attachments : 2 copies colour passport-size photos, 1 copy biography, 1 copy NID photocopy.

11. Proposer's Name, Member No & Signature :

12. Supporter's Name, Member No & Signature :

13. I hereby undertake that I shall abide by the constitution of the Samity, the prevailing laws of the country and the customs.

Yours faithfully

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Applicant's Signature

Part 2 : Authority's Approval (To be filled in by office)

After reviewing the above information, I recommend granting of membership.

Convener (Selection Sub-Committee)

Member Secretary (Selection Sub-Committee)

President

General Secretary

No-

Part 3 : (Receipt of Payment)

Name :

National ID No :

Application Form & Pay Order/Bank Deposit Receipt and Date :

Taka

(In words) : Received.

Treasurer

Receiver

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