MEMBERSHIP FORM Personal Detail Title Select Mr. Ms. Mrs. Others First Name* Last Name* Date of Birth* 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 PAN No Email* Mobile* Contact Detail Address* Country* Select a Country INDIA AFGHANISTAN ALBANIA ALGERIA AMERICAN SAMOA ANDORRA ANGOLA ANGUILLA ANTARCTICA ANTIGUA AND BARBUDA ARGENTINA ARMENIA ARUBA AUSTRALIA AUSTRIA AZERBAIJAN BAHAMAS BAHRAIN BANGLADESH BARBADOS BELARUS BELGIUM BELIZE BENIN BERMUDA BHUTAN BOLIVIA BOSNIA AND HERZEGOVINA BOTSWANA BOUVET ISLAND BRAZIL BRITISH INDIAN OCEAN TERRITORY BRUNEI BULGARIA BURKINA FASO BURUNDI CAMBODIA CAMEROON CANADA CAPE VERDE CAYMAN ISLANDS CENTRAL AFRICAN REPUBLIC CHAD CHILE CHINA CHRISTMAS ISLAND COCOS (KEELING) ISLANDS COLOMBIA COMOROS CONGO CONGO (DRC) COOK ISLANDS COSTA RICA CĂTE DIVOIRE CROATIA (HRVATSKA) CUBA CYPRUS CZECH REPUBLIC DENMARK DJIBOUTI DOMINICA DOMINICAN REPUBLIC EAST TIMOR ECUADOR EGYPT EL SALVADOR EQUATORIAL GUINEA ERITREA ESTONIA ETHIOPIA FALKLAND ISLANDS (ISLAS MALVINAS) FAROE ISLANDS FIJI ISLANDS FINLAND FRANCE FRENCH GUIANA FRENCH POLYNESIA FRENCH SOUTHERN AND ANTARCTIC LANDS GABON GAMBIA GEORGIA GERMANY GHANA GIBRALTAR GREECE GREENLAND GRENADA GUADELOUPE GUAM GUATEMALA GUINEA GUINEA-BISSAU GUYANA HAITI HEARD ISLAND AND MCDONALD ISLANDS HONDURAS HONG KONG SAR HUNGARY ICELAND INDONESIA IRAN IRAQ IRELAND ISRAEL ITALY JAMAICA JAPAN JORDAN KAZAKHSTAN KENYA KIRIBATI KOREA KUWAIT KYRGYZSTAN LAOS LATVIA LEBANON LESOTHO LIBERIA LIBYA LIECHTENSTEIN LITHUANIA LUXEMBOURG MACAO SAR MACEDONIA MADAGASCAR MALAWI MALAYSIA MALDIVES MALI MALTA MARSHALL ISLANDS MARTINIQUE MAURITANIA MAURITIUS MAYOTTE MEXICO MICRONESIA MOLDOVA MONACO MONGOLIA MONTSERRAT MOROCCO MOZAMBIQUE MYANMAR NAMIBIA NAURU NEPAL NETHERLANDS NETHERLANDS ANTILLES NEW CALEDONIA NEW ZEALAND NICARAGUA NIGER NIGERIA NIUE NORFOLK ISLAND NORTH KOREA NORTHERN MARIANA ISLANDS NORWAY OMAN PAKISTAN PALAU PANAMA PAPUA NEW GUINEA PARAGUAY PERU PHILIPPINES PITCAIRN ISLANDS POLAND PORTUGAL PUERTO RICO QATAR REUNION ROMANIA RUSSIA RWANDA SAMOA SAN MARINO SĂO TOMĂ AND PRĂNCIPE SAUDI ARABIA SENEGAL SERBIA AND MONTENEGRO SEYCHELLES SIERRA LEONE SINGAPORE SLOVAKIA SLOVENIA SOLOMON ISLANDS SOMALIA SOUTH AFRICA SOUTH GEORGIA AND THE SOUTH SANDWICH ISLANDS SPAIN SRI LANKA ST. HELENA ST. KITTS AND NEVIS ST. LUCIA ST. PIERRE AND MIQUELON ST. VINCENT AND THE GRENADINES SUDAN SURINAME SVALBARD AND JAN MAYEN SWAZILAND SWEDEN SWITZERLAND SYRIA TAIWAN TAJIKISTAN TANZANIA THAILAND TOGO TOKELAU TONGA TRINIDAD AND TOBAGO TUNISIA TURKEY TURKMENISTAN TURKS AND CAICOS ISLANDS TUVALU UGANDA UKRAINE UNITED ARAB EMIRATES UNITED KINGDOM UNITED STATES UNITED STATES MINOR OUTLYING ISLANDS URUGUAY UZBEKISTAN VANUATU VATICAN CITY VENEZUELA VIET NAM VIRGIN ISLANDS VIRGIN ISLANDS (BRITISH) WALLIS AND FUTUNA YEMEN ZAMBIA ZIMBABWE State State Select a State ANDHRA PRADESH ARUNACHAL PRADESH ASSAM BIHAR CHANDIGARH CHATTISGARH DADRA AND NAGAR HAVELI DELHI GOA GUJARAT HARYANA HIMACHAL PRADESH JAMMU AND KASHMIR JHARKHAND KARNATAKA KERALA LAKSHADWEEP MADHYA PRADESH MAHARASHTRA MANIPUR MEGHALAYA MIZORAM NAGALAND ORISSA PONDICHERRY PUNJAB RAJASTHAN SIKKIM TAMILNADU TELANGANA TRIPURA UTTAR PRADESH UTTARANCHAL WEST BENGAL City* Pin/Zip Code* Citizenship* Select Indian Resident Non Resident Indian Foreign National How can I help Quame Uruuj Foundation TEAM Reference #1 Reference #2 Name Occupation Address Contact No. Email Name Occupation Address Contact No. Email SUBMIT