ASEA Membership Application Form

⚠️ Instructions: Fields with * are mandatory. Max File Size: Photo 500KB, Sign 200KB.

1. Personal Details

Full Name *

Blood Group *

Date of Birth *

Gender *

Caste *

Occupation *

Department Name

WhatsApp Number *

Email ID *

2. Address

Current Address *

Permanent Address same as Current

Permanent Address *

3. Nominee

Nominee Name *

Relation *

Nominee Age *

Nominee Mobile *

4. Membership & Payment

Prime Member (₹500) Elite Member (₹1000)

Emergency Fund Contribution *

₹1500 (One-Time) ₹500 (3-Installments)

Extra Contribution (Optional)

5. Uploads

Adhar Card/PAN Card/Voter ID (Max 500KB) *

Photo (Max 500KB) *

Signature (Max 200KB) *

6. Declaration

I declare that all information provided is true and correct. *

ACADEMY OF SKILL & EXCELLENCE FOR ADIVASIS