Membership Form

To,
Executive Director,
ama adh!kar / HRPC, Bhubaneswar, Odisha

Subject: Application for Membership

Dear Sir,

I hereby apply for ama adh!kar / HRPC’s membership. I have read ama adh!kar / HRPC’s objectives and activities, and willing to work for promotion of ama adh!kar / HRPC’s movement at all levels of deprived section of the society in Odisha. My Bio-data is given below for your consideration;

Type of Membership
Personal Details
Name : Date of Birth :
Address : Nationality :
Contact No. : PAN No. :
E-mail :    
Professional Details
Professional Qualifications : Present Occupation :
Nature of work : Name of the Organization :
Organisation Address :
Other Details
1. Important Positions Held, if any:
2. Associated with other Institute / Organization /NGO / Government:
3. Have you been a member of any Political Party? If yes, please state details:
4. Have you ever been found guilty of civil or criminal offence? If yes, please state details:
5. Has ever any case been registered against you by the police? If yes, please state details:
Any other information
1. Whether undertaken any public welfare / social service activity?
2. Reasons for seeking ama adh!kar / HRPC’s membership:
3. References of the members of ama adh!kar / HRPC’s Staff or any eminent person of repute:
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UNDERTAKING

1. I hereby affirm my allegiance to the constitution of India and undertake to uphold its provisions in my personal, official and public life.

2. I hereby certify that all the information furnished with this application are true. That I will follow the Code of Ethics approved by the General Body of ama adh!kar / HRPC.

3. I undertake that I will not make use of ama adh!kar / HRPC’s Membership for any personal gain. In case of violation of the undertaking or any breach of conduct, ama adh!kar / HRPC will be free to terminate my membership.

Place :   Signature
Date :    

Contact Us:
Executive Director
ama adh!kar / HRPC,
Sri Ram Niwas, Plot No-2232, Sri Ram Nagar, Old Town
Bhubaneswar-751002, Odisha, India

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