Membership Form

(Membership form free; Membership charges Rs.20/-)

For Students only:
Delhi Public Library
(A Govt. of India Organization, Min. of Culture)
Name of the School/College with Complete Address:
_______________________________________________________________
_______________________________________________________________
Class/Course of Study : ________________________
Aadhar Card No.:_______________________ Form Serial No.:_________
Affix your
recent color
Photograph

Type of Membership Needed:

Child Membership/Adult Membership
( Tick whichever is applicable) : Child DVD Membership/Adult Membership
Mr./Ms./Dr./Any Other/_____________
Surname: _______________ Name :_________________________________

*Declaration by parent in case of Minor:

I_______________________ on the behalf of my Son/Daughter
________________________ abide by the Rules of DPL for Books/CDs taken
by them. Office Address:_____________________
_______________________________ Telephone No.:___________

Fathers/Mothers Name :__________________________________________

Date of Birth : Date________Month_________Year_________
Age: ______ Sex: Male/ Female ( Tick) Qualification: ______________
Residential Address : _____________________________________________
_______________________________________________________________
City :______________ Pin :_____________
Permanent/Alternate Address: _____________________________________

Signature

Introducer Details:
I know the applicant and verify his/her signature, address and also
recommended to be a member of the Delhi Public Library.
*(Should be attested by a MP/ MLA/ Councilor/ Gazetted Officer/ MBBS/
BAMS/ BUMS Doctor)
Name: __________________________ Design.: _______________________
Office Address :__________________________________________________
_________________________________________________
Telephone/Mobile No.:___________________

___________________________________________
Signature
Email: ____________________________

Mobile:_________________

Landline:____________

(Space of Stamp)

Are you a existing member of DPL : YES/NO

(For Office Use)

Membership No.:___________________ Date of Expiry :_________
Details of address proof provided : Ration Card/Election I-Card/Govt. Office
ID-Card/Passport/Driving License/CGHS.ESI Card/Current Electricity Bill.

If Yes, since _____________ State the Membership No.: ________________

1/2/3 BT Received :__________________

Category : Student/Employed/Unemployed/Retired/Housewife/Others

Signature of the Candidate (With Date)

Signature of I/C