Disaster Management Forum
Membership Application Form
  • Personal 1
  • Personal 2
  • Address
  • Health
  • Academic
  • Professional
  • Membership
  • Declaration
  • Document
Personal 1
1). Name *

A value is required.
10). Father's Name *

A value is required.
2). Date of Birth *

Please select Day.

Please select month.

Please select year.
11). Mother's Name *

A value is required.
3). Gender *

Please select Gender.
4). Marital Status *

Please select Marital Status.

13). Mobile Number * (10 Digit Mobile No.)

A value is required.

Invalid format.
5). Nationality *

Please select Nationality.
14). Emergency Number *

A value is required.Invalid format.
6).Height ( In cm )*

Please select Height.
15). Land Line Number
7). Weight ( In Kg )*

Please select Weight.
16). Email ID : 1 *

A value is required.Invalid format.
8). Blood Group *

Please select Blood Group.

Please select RH Factor.
17). Email ID : 2
9). Identification mark on your body *

A value is required.
 
   
 

Personal 2
19). PAN Card No.
21). Driving License No.
20). Passport No.
22). Swimming Skill *

Please select your Swimming Skill.
23). Languages : Comfortable for Communication *
Laguage Speaking Ability Writing Ability Understanding Ability
 
   
 
Address
24). Present / Mailing Address *

Address is Required.
25). Permanent Address
City *

A value is required.
City
PIN Code *

A value is required.Invalid format.
PIN Code
Country *

Please select an item.
Country
 
Health Profile
26). Any Physical Disability * Yes NO
 
27). Health Complications or Problems that could restrict you from any operations.
Eye Sight
Cardiac
Hypertension
Any Allergy or Sensitivity
Epilepsy

Any Other ( Pl Specify )
 
Academic Profile
28). Qualification *
Year of Passing Board/ University

A value is required.Invalid format.

A value is required.

Stream:

Stream:

Stream:

Stream:

Stream:
     
 
Professional Profile
29). Current Profession *
A value is required.
 
30). Professional Experience Details * (Starting from cureent position)
Position Held From To Period (Days) Employer
31). Total Years Of Experience (Approx)  
32. Emergency / Disaster Response Experiences
Name of the Disaster Year Position Core Responsibilities
33). Emergency / Disaster Response trainings participated * Yes No
34). Significant Contribution to Humanitarian Sector
 
35). Core Area (s) of Competency *

Please select an item.
36). Core Area of Interest for Humanitarian Response *
  Pre Disaster
Please select an item.
  During Disaster
Please select an item.
  Post Disaster
Please select an item.
37). Reference *
Reference 1 Reference 2
Name
A value is required.
Designation
A value is required.
Address
A value is required.
Contact No.
A value is required.Invalid format.
Email
A value is required.Invalid format.
Name
A value is required.
Designation
A value is required.
Address
A value is required.
Contact No.
A value is required.Invalid format.
Email
A value is required.Invalid format.
 
38). Membership Subscription ( Please Choose Any One Category - Renewal is Mandatory ) *
  Membership Category Membership Type Subscription Fee Regd. / Annual Renewal Fee Choose one Option
a Titanium Members Patrons Rs. 25,000 Rs. 100
b Platinum Members Institutional Membership Rs. 25,000 Rs. 100
c Diamond Members Life Membership Rs. 15,000 Rs. 100
d Gold Members Annual Membership Rs. 1,000 Rs. 100
e Silver Members Forum Volunteers Rs. 100 Rs. 100
 

Note : Membership can be upgraded
Gold Members can subscribe for Multiple Numbers of Years

You have Chosen :
A value is required.
 
Declaration

I do hereby declare that the above information furnished is true to the best of my knowledge.
I am willing to subscribe the membership of Disaster Management Forum - Centurion University .
I do hereby declare that I am aware of my responsibilities and abide by all the rules prescribed for membership.
I do not subscribe the ideas or associate myself with any groups or individual associated with any fundamentalism, terrorism or anti social activities in any part of the globe.
I am aware that Centurion University reserves the right to reject my application or membership at any given point of time for any indiscipline or violating rules .

*
Yes Please make a selection.

 
Please upload below documents
       
1. Recent photo (passport) : * KB. File Size. * Photo required.
2. Updated Resume : * KB. File Size. * Resume required.
3. Identity Proof : * KB. File Size. * ID Proof required.