Samaj Membership

Last Name of the Family

Name of the Village in India

Current Home Address, City, St Zip

Number of people at the current address

First Name | Birthday (List each member at the current address)

List each name on a separate line: for example - John, 01/01/1960 (Date will help us to organize by age for future events).

Your Cell Number

Your Spouse's Cell Number

Your Email Address

Your Spouse's Email Address

Additional Cell and Email Address

Add the Cell number and Email address of other members of the family.

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