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Dr. Ambedkar Center for Social Change (Registration Form)




First Name*			Last Name*
Father's Name*			Age*
Sex			Current Status
Mother's Name*			Resident of
Qualification*			Computer Literate
If others please specify			Computer Literate
District*			E-mail Address*
Current Address*
Block			Tehsil
Mobile (1)*			Mobile (2)
Aim of Supporting*
Did you previously participated in any Andolan/Anshan/Social Activities			Mention Date
Give details of activity			Mention Place
How can you help us *

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IMP : Attach your photo if detail submitted without photo than it may not be Updated later.