SHOSHIT SAMAJ DAL

CENTRAL OFFICE,PURANI JAKKANPUR,PO-GPO,PS-GARDANIBAGH, PATNA-800001

Mob: 9334016411, 9431200894

Membership Application

Valid till: 31st December 2026 Note: Incomplete or false information is liable to be rejected.

1. Name:

2. Father's Name:

3. Local Address:

4. Permanent Address:

5. Category (SC/ST/EBC/OBC/Gen):

6. Membership Fee:

Any other information, if any:

7. Membership Approved By

8. Secretary / President

Signature of Applicant