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

First Name

Middle Name

Last Name

Beneficiary Member LM Member
Beneficiary Member

Sex

MaleFemale

DOB (MM/dd/yyyy)

Age

Qualification

IADVL Member LM NO

State Branch of IADVL

	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

Signature (applicant)