This document is a monthly subscription and blood donation application form for Darul Khair Education and Welfare Society located in Bijapur, Karnataka, India. It requests basic contact information from applicants such as name, address, date of birth, phone number and email. Applicants can choose to join as a monthly member, blood donor or both. By signing, applicants agree to abide by the organization's rules and certify that the information provided is true. Contact details are provided at the bottom for the organization's website and phone numbers.

1. Reg No.:BIJ-S-221/2013-14
DARUL KHAIR
Education and Welfare Society ( DEWS )
Saquaf Roza Bijapur 586101 Karnataka INDIA
Phone: 08352-256789
MONTHLY SUBSCRIBTION & BLOOD DONATION
APPLICATION FORM
Date: ____/____/____
Place:______________
First Name
40x45
Middle Name
Sur Name
Edu
ca
t
/
Full Address
i
/
POB
y
ciet
So
Date of Birth
nd Welfar
e
na
o
Reg No.:BIJ-S-221/2013-14
DEWS
Phone
Email ___________________________
DECLARATION & INFORMATION
( Please tick in a box in which you like with join us )
Monthly Member
Blood Donation
I hereby certify that the above mentioned information is true the best of my knowledge.
I agree to abide by the Rules and Regulations laid down in the Prospectus and those
which may be formulated later.
Thank You....
My Blood Group is ____________________
Signature of Applicant
Log in to : www.darulkhair.simdif.com
Email :
darulkhair.10@gmail.com
+91 9886701082
+91 8867245321
+91 9845876205