District State National International
1.	Name	:
	Image	:
2.	Father / Husband Name	:
3.	Sex	:	Male Female
4.	Residental Address	:
5.	Occupation	:
6.	Occupational Addres	:
	City	:
	District	:
	State	:
	Country	:
7.	Educational Qualification	:
8.	Date of Birth	:
9.	E-mail	:
10.	Phone Number	:
11.	Blood Group	:
12.	Marital Status	:	Yes No
13.	Area Police Station Address	:
14.	Any Participation in Public Activities	:	Part Labour Union NGO
15.	Do You Want to Donate?	:	Eyes Body Blood
16.	Are You a Income Tax Assesse?	:	Yes No
	If 'Yes' Write Your PAN No.	:
17.	Do You Get Any Benefit From State / Central Government Welfare Scheme?	:	Yes No
18.	Do You Have Ration Card?	:	Yes No
19.	Do You Have Voter's ID Card?	:	Yes No
20.	Do you have Passport?	:	Yes No
21.	Do you like to Participate in Self help Groups?	:	Yes No
22.	Details of 'Human Rights Monthly Magazine' Magazine 'Subscription required'	:	1 Year 5 Year 10 Year 20 Year
	Date		Introducer Name
	Verification Code*
Membership Details: Domestic (only india) Joint Membership : Rs. 500 (validity 3 years) State Patron : Rs. 5000 (validity 2 years)
International Joint Membership : Rs. 5000 (validity 3 years) State Patron : Rs. 25000 (validity 2 years)