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Become WNHO Business Associate & Earn. Business Associate Membership Fee Rs. Ten Thousand only. Can Start Health Club Activity. Fill the form for eligibility WNHO HEALTH CARE PVT.LTD.(Health & Wealth Business Forum-Club) LIFE MEMBERSHIP FORM Please fill this form CORRECTLY with* is COMPULSORY A] INTRODUCER DETAILS FULL NAME(AS PANCARD) : ……………………………………………………………………… USER ID* : ……………………………………… MOBILE NO*/ EMAIL .................... B] PERSONAL DETAILS NAME* : …………………………………………………………….. GENDER : MALE/FEMAL MARITAL STATUS: SINGLE/MARRIED/OTHER DATE OF BIRTH* (DD/MM/YYYY): ..................... NATIONALITY : ………………………………… STATUS : RESIDENT INDIVIDUAL/NON RESIDENT/FOREIGN NATIONAL PAN NUMBER* : ........................................................... (PLEASE ATTACHED SELF ATTESTED COPY OF PAN CARD) PREFERRED USERNAME*: EMAIL ADDRESS* : …………………………………………… MOBILE NUMBER* : ……………………………………. C] ADDRESS DETAILS (PLEASE ATTACH SELF ATTESTED COPY OF ADDRESS PROOF, LICENCE, PASSFORT, BILLS ETC) RESIDENT ADDRESS : ……………………………………………………………………………............... ................................................................................................................................... CITY/TOWN : ………………………………………………… PIN CODE : …………………………… STATE : ………………………………………………… COUNTRY : …………………………………………….. PERMANENT ADDRESS IF DIFFERENT FROM ABOVE PERMANENT ADDRESS : …………………………………………………………………………………………………………………………… CITY/TOWN : ………………………………………………… PIN CODE : ………………………………… STATE : ………………………………………………… COUNTRY : …………………………………… D. BANK DETAILS (PLEASE ATTACH SELF ATTESTED COPY OF BANK ACCOUNT DETAILS) ACCOUNT HOLDER NAME : ……………………………………………………………………………. BANK NAME : …………………………………………………………………………… ACCOUNT NUMBER : ……………………………………… ACCOUNT TYPE : SAVING/CURRENT BRANCH NAME : …………………………………………… IFSC CODE : …………………………………………… Declaration: I hereby declare that the details furnished above are true and correct to the best of my knowledge and belief and I undertake to inform you of any changes therein, immediately. In case any of the above information is found to be false or untrue or misleading or misrepresenting, I am aware that I may be held liable for it. I hereby acknowledge that I have reviewed and understand this WNHO Health Care Ptv.Ltd application and agreement including all of the document defined herein as “materials” which are incorporated herein, and that I agree to be bind by all of them. ………………………………………………….. ....................................... Signature of the Applicant Date : (dd/mm/yyyy) ------------------------------------------------------------------------------------------------------------------- For office use only originals verified and self-attested document copies received(yes/no) Name: Signature: Company Stamp: