Declaration for Ladies


SHREE SAMASAT KHADAYATA SURKSHA TRUST

(C/o. SHREEJI HOSPITAL, STATION ROAD, ANKLESHWAR- 393 001 PHONE: 47488)
Form No            

   AFFIDAVIT 

   FOR OFFICE USE

                                                                                                                                                       SKS NO

                                                                                                                                                       FILE NO

  I undersigned  Mrs._______________________________________________________

 Age Year_________________Address_____________________________________

 As per my religion, I declare as follows:

 (1)       Before marriage my name was Ms.____________________________________

 (2)       After my marriage my name is Mrs.___________________________________

 (3)       My Birth Date is _____________.And Marriage Date____________________

 (4)       In future, if this details were found to be incorrect that case whatever amount

          is credit in my name or paid to me will be  consider to be forfeited and

          my membership  will be cancelled.

 

Hereby I am signing this form after understanding it and sign on dt._______Month_________Year_______                     Signature         : ________________

Place                 :________________

Husband's Sign :________________

Address            :________________

                            ________________

    

Witness Name 1:___________________________                2.__________________________

Address  ___________________________                                                                                                                               __________________________

                                                                                                                              ___________________________

Sign                  :___________________________                     ___________________________              




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