Declaration of "Gift to the Nation"

Declaration of "Gift to the Nation"

In the hope that I may help others,
I do hereby declare the wish to Donate my :

Eyes only All organs Whole Body

for : Therapeutic Use and Anatomical use

to the Nation if medically acceptable, to take effect upon my death.
I have advised my relatives to notify on any Medical Institute / Eye Bank / Hospital upon demise so that my this wish is fulfilled.

"Enrollment as a "Life-Line Volunteer"

I pledge to Donate Blood whenever asked by 'A-TRFC' for any needy patient Subject to my medical fitness at that time.

I also Authorise 'A-TRFC' to print my name along with required infromation in all or any of future issues of 'ARM-CARD' Directory as 'A-TRFC' may deem fit.

Personal Details of "Donor"

Name ............................................................................................
Blood Group ................... Date of Birth.......................................
Voter's I.D. Card / Ration Card / Diriving Licence / Passport or
Pan No. .................................... Place...................................
Authority........................................ Expiry Date.........................
I am allergic to.................................................................................
Address ......................................................................................
.......................................................................................................
Tel / Fax.........................................................................................

In case of Emergency please contact the following :

Name (s) ......................................................................................
Address (es) ...............................................................................
........................................................................................................
Tel / Fax .......................................................................................

Corporate / Establishment Details

for: Hon'rary Empanelment with 'A-TRFC'

Company / Firm ...............................................................................
Address.........................................................................................
.......................................................................................................
City ............................................ Pin..............................................
Tele/Fax No...................................................................................

Our special offers / Discounts/Privileges / to 'ARM-CARD' Holders are as under :

....................................................................................
....................................................................................
....................................................................................
....................................................................................
....................................................................................
....................................................................................
....................................................................................
...................................................................................
.......................................................................................................
(Enclose Establishment Details on your Co's Letter-Head also)

I/ We the undersigned warrant that the information included in this appliation is true and correct. I/We understand that 'A-TRFC' reserves the right to decline the application without giving any reason and without entering into any correspondence. It is my/ our responsibility to obtain terms and conditions applying to Empanelment (any category) from 'A-TRFC' and read the same. I / we would be bound by the said terms and conditions as may be in force from time to time. empanelment/ Advertisement/ if issued to me / us will be deemed to be acceptance of those terms and conditions. Thanking You & with regards.

Yours Sincerely,

Name....................................................................................................
Current Designation .........................................................................
Tel/ Fax No.....................................................................................
Date:....................................... Signature ..........................................................

Registration Form

I / We request 'A-TRFC', to accept my/our application for 'ARM-CARD' membership under the following category:

Ordinary Family Corporate
1 Yr. Life

My particulars are given as under :
Name .............................................................................................
Male/Female ........................Married/Unmarried............................
Date of Birth :..............................No. of Dependents.....................
Father’s Name :..............................................................................
Spouse Name :...............................................................................
No. of Children................Male :.......................Female : .................
Address : ......................................................................................
.......................................................................................................
Tele/fax. No. ..................................................................................
Line of Profession : Business/ Service/ self Employed / Others
(Please specify) ...........................................................................
Office Address ..............................................................................
.........................................................................................................
Tele/Fax No.....................................................................................

Any Priority processing applicable ? Yes No
if yes please specify.....................................................................

Please sign this authorisation :

I / We do here by apply for the issue of an 'ARM-CARD' to me / us and declare that the information included in this application is true and correct. I / We accept that
'A-TRFC' is entitled to accept or reject this application without assigning any reason whatsoever. It is my / our responsibility to obtain terms and conditions applying for the issuance and use of the 'ARM-CARD' from 'A-TRFC' and read the same. I / We would be bound by the said terms and conditions as may be inforce from time-to-time and use of the 'ARM-CARD' will be deemed to be acceptance of those terms and conditions.

Thanking you and with regards.

Your sincerely,

Dated:......................................Signature .................................................

This is how you can participate in the

Save Humanity Campaign

a) Enrollment as a "life-line" volunteer.
b) Declaration of "Gift to the Nation".
c) Hon'rary Empanelment with 'A-TRFC'
d) Joining a Girl Child Gift -Adoption programme.
e) My own way (Details enclosed).
Tubectomy / Vasectomy/ others.
f) 'ARM-CARD' Membership
g) Donation of : Rs.100/- only.
Rs. ..............................only
h) All the above except ...................................

(PleaseTick and Sign Accordingly)

Yes! I wish to participate in the 'Save Humanity Campaign'

as mentioned above. My particulars are given as under

I enclose a Cheque/Draft/P.O. No.................................
dated............................ for Rs................................only
Bank/P.O.(Name).............................................................
Branch..................................................City..................................

in favour of : 'Arogyadham-The Royal Families Club'.

as donation. Please send me further necessary details.

................. ..........................

Date Signature

Name ........................................................................

Address............................................................................
......................................................................................

Tele/fax No................................................................

Mail coupon to : 'Save Humanity Campaign',
Post Box No. 10577, New Delhi-110034