Membership Form
Name of Member:
Mobile No:
WhatsApp No:
Date of Birth :
Residential Address:
Email:
Education Qualification:
Blood Group:
Select Blood Group
A+
A-
B+
B-
AB+
AB-
O+
O-
Member Photo:
Center Code:
Akshaya Centre Location:
Address of Akshaya Centre:
District
Select District
Trivandrum
Kollam
Pathanamthitta
Alappuzha
Kottayam
Idukki
Ernakulam
Thrissur
Palakkad
Malappuram
Kozhikode
Wayanad
Kannur
Kasaragod
Block Name:
Select Block
Taluk Name:
Select Taluk
Post Office:
PIN Code:
Akshaya Care Member :
Select Answer
Yes
No
Are you enterpreneur / lessee?
Select Answer
Enterpreneur
Lessee
If you are not the designated Akshaya entrepreneur, kindly provide the name and mobile of the entrepreneur?
Akshaya Started Year :
Select 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
I acknowledge that the above information is provided with my knowledge and consent and that taking up membership in FACE is of my own free will.
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