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Office Address:

Office Address: Avenue d'Auderghem 199 Brussels 1040 Tel: +32.2.646 3202 Fax:+32.2.646 3202 Mobile: +32(0)494 721934              +32(0)479 701106 E-mail: puja_brussels@yahoo.com Website: www.puja-brussels.org. Membership application Form. Membership: Individual/Family.

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Office Address:

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  1. Office Address: Avenue d'Auderghem 199Brussels 1040Tel: +32.2.646 3202Fax:+32.2.646 3202Mobile: +32(0)494 721934             +32(0)479 701106 E-mail: puja_brussels@yahoo.com Website: www.puja-brussels.org Membership application Form Membership: Individual/Family For Family only: Number of family members Mr./Mrs./Miss Name: Address: Address1: Tel./Mobile: E-mail: Proposed by (should be registered member): Name: Registration No. Date of Registration: Registration valid till: Family Individual € € Membership Fees paid: 10 25 “I do agree with the objectives of the organization and believe that I also fulfill the criteria of the membership set by the organization. As a member, I will abide with all directives, regulations and by-laws of the constitution.” Name & Signature of the applicant: Date: Place: Signature of the member who proposed: Date: Place: For official use only Approved by (at least 3 out of 5 Executive Members): Name and signature 1. 2. 3. Assigned Membership Number If refused, mention the proposed date to place the application to the General Assembly. Proposed date:

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