06/04/202506/04/2025 Membership Form Membership Form Fill out the form carefully for registration Member Name First NameLast Name Birth Date Please select a month January February March April May June July August September October November December Month Please select a day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Day Please select a year 2025 2024 2023 2022 2021 2020 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 Year Gender Please Select Male Female N/A Residential Address Street Address Street Address Line 2 CityState / Province Postal / Zip Code E-mail example@example.com Mobile Number Profession Membership Type - Individual Membership - Organizational Membership - Student Membership (for students only) - Honorary Membership (for distinguished individuals) Reason for joining Please briefly describe why you want to join Equanimity Welfare Organization and what you hope to achieve through your membership: Skills and Expertise Please list any relevant skills or expertise you can contribute to the organization: Volunteer interest - Please indicate if you are interested in volunteering for any specific areas of the organization, such as: - Event planning - Fundraising - Community outreach - Administrative support Membership Fees - Please indicate your preferred method of payment: - Annual subscription - Monthly subscription - One-time payment Payment Details •Payment method: •Payment date: •Receipt number Reference - Please provide the names and contact information of two references: Additional Comments Declaration I hereby declare that the information provided is true and accurate. I understand and agree to abide by the rules and regulations of Equanimity Welfare Organization. Signature ContinueContinue Should be Empty:
