Membership Application

Full Name *

Father's Name *

Mother's Name

Date of Birth *

Citizenship Number *

Blood Group -- Select -- A+ A- B+ B- AB+ AB- O+ O-

Occupation -- Select Occupation -- Retired Government Employee Retired Teacher Farmer Business Housewife Social Worker Retired Army/Police Health Worker Shopkeeper Labour Pensioner Other

Phone Number *

Province * -- Select Province -- Province 1 Madhesh Province Bagmati Province Gandaki Province Lumbini Province Karnali Province Sudurpashchim Province

District * -- Select District --

Local Level * -- Select Local Level --

Ward Number * -- Select Ward --

Photo (JPG, PNG) *

Max 5MB. Recent passport-sized photo recommended.

Citizenship Front (JPG, PNG) *

Max 5MB. Clear image of citizenship front side.

Citizenship Back (JPG, PNG) *

Max 5MB. Clear image of citizenship back side.