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PERSONAL INFORMATION
fields marked with
*
are compulsory
Account Details
User Name
*
:
Password
*
:
Re-enter Password
*
:
Personal Details
First Name
*
:
Father's / Husband's Name
*
:
Last Name
*
:
Gender
*
:
-Select-
Male
Female
Marital Status
*
:
-Select-
Single
Married
Divorced
Widow
Date of Birth
:
-Select-
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
-Select-
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
-Select-
1927
1928
1929
1930
1931
1932
1933
1934
1935
1936
1937
1938
1939
1940
1941
1942
1943
1944
1945
1946
1947
1948
1949
1950
1951
1952
1953
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1955
1956
1957
1958
1959
1960
1961
1962
1963
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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
Age:
Place of Birth
:
City
Country
Mobed/Non-Mobed
*
:
-Select-
Mobed
Non-Mobed
Nationality
*
:
Correspondence Mailing Address
Country
*
:
State
*
:
City
*
:
Address1
*
:
Address2
:
Pin / Zip Code
*
:
Tick here if correspondence and permanent mailing address is same
Permanent Mailing Address
Country
*
:
State
*
:
-- State --
City
*
:
-- City --
Address1
*
:
--Select --
Baug / Parsi Colony
Others
-- Select Baug / Parsi Colony --
Address2
:
Pin / Zip Code
*
:
Other Contact Details
Mobile No.
*
:
Email-Id
: