Patron Members Application Form

LIFE INSURANCE AGNTS’  FEDERATION OF INDIA

Register No. 2924/2000

MIG-II B-37, Gullalapalem, Visakhapatnam – 530011

Tel.:089125777708, Fax : 0891-2741663

BIO-DATA FORM

If Renewal Please Indicate ID NO.

Note:

  1. Proper Address is necessary for Delivering Communications and Journals.
  2. Please fill in English Capital Letters Only.

SEX*:

NAME*
HOUSE NUMBER*
STREET*
VILLAGE / TOWN
POST OFFICE
DISTRICT* PINCODE*:
STATE*
TELEPHONE : (M*)(R)(O)
DATE OF BIRTH*
AGENCY CODE DATE APPOINTED
BRANCH CODE* NAME OF BRANCH*
NAME OF DIVISION*
NAME OF ZONE*
CLUB MEMBERSHIP*

I request you to enrol me as patron / Life Patron member of LIAFI. I enclose herewith Cash / Bank Draft No. Date for Rs. 500/- / Rs. 5000/- Drawn on towards my contribtion for the current year in favour of Life Insurance Agents Federation of India, payable at visakhapatnam.

Sign (Full Name).