Delhi Public Library Membership Form

Membership Form (Membership form free; Membership charges Rs.20/-) For Students only: Delhi Public Library (A Govt. of India Organization, Min. of Culture) Name of the School/College with Complete Address: _______________________________________________________________ _______________________________________________________________ Class/Course of Study : ________________________ Aadhar Card No.:_______________________ Form Serial No.:_________ Affix your recent color Photograph

Type of Membership Needed: Child Membership/Adult Membership ( Tick whichever is applicable) : Child DVD Membership/Adult Membership Mr./Ms./Dr./Any Other/_____________ Surname: _______________ Name :_________________________________

*Declaration by parent in case of Minor: I_______________________ on the behalf of my Son/Daughter ________________________ abide by the Rules of DPL for Books/CDs taken by them. Office Address:_____________________ _______________________________ Telephone No.:___________

Father’s/Mother’s Name :__________________________________________ Date of Birth : Date________Month_________Year_________ Age: ______ Sex: Male/ Female ( Tick) Qualification: ______________ Residential Address : _____________________________________________ _______________________________________________________________ City :______________ Pin :_____________ Permanent/Alternate Address: _____________________________________

Signature

Introducer Details: I know the applicant and verify his/her signature, address and also recommended to be a member of the Delhi Public Library. *(Should be attested by a MP/ MLA/ Councilor/ Gazetted Officer/ MBBS/ BAMS/ BUMS Doctor) Name: __________________________ Design.: _______________________ Office Address :__________________________________________________ _________________________________________________ Telephone/Mobile No.:___________________

___________________________________________ Signature Email: ____________________________

Mobile:_________________

Landline:____________

(Space of Stamp)

Are you a existing member of DPL : YES/NO

(For Office Use) Membership No.:___________________ Date of Expiry :_________ Details of address proof provided : Ration Card/Election I-Card/Govt. Office ID-Card/Passport/Driving License/CGHS.ESI Card/Current Electricity Bill.

If Yes, since _____________ State the Membership No.: ________________

1/2/3 BT Received :__________________

Category : Student/Employed/Unemployed/Retired/Housewife/Others

Signature of the Candidate (With Date)

Signature of I/C