ECOSAVERS Youth Network Membership Application Form Date of Application: / / Name : SEERHEEN IFTISHA Father/Mother/ Guardian Name : APSARI BEGUM School/Collage/Institute/others : SRI JAYADEV COLLEGE OF EDUCATION AND TECHNOLOGY Gender: Female Date of Birth: 04 oct 2005 Age 21 (should be 1 7 - 30 years) Present Address (With PIN Code) : AT - ANDILO PO/PS BALIANTA DIST - KHORDA PIN - 754101 Permanent Address (With PIN Code): AT - ANDILO PO/PS BALIANTA DIST - KHORDA PIN - 754101 E - Mail: _______________________________ Contact No : 82603 55141 Blood Group: _________ B+ ___________ Occupation: Field of interest: ______________ _______________________________________ ___________________________________________________________________ DECLARATION I __________________________ hereby declare that the above statements are true to my knowledge. I do hereby declare that I desire to be an active member of “Eco - Savers - Youth Network”. Da t e: Signature of the member Facilitated by : People’s Cultural Centre (PECUC) Email - pecuc.ecosavers@gmail.com, www.pecuc.org