Application for Membership

Name *

Date of Birth*

Age*

Phone / Mobile No*

Permanent Address*

District*

Name of Media*

Designation*

Blood Group*

Place of Work*

Wages*

Office Address*

Experience (With Details)*

Whether any Membership in similar Organization*

Vehicle No*

E-mail ID*

Password*

Upload Photo*

Photo size should be 4cm x 5cm

I hearby declare that I will abide by the constitution of the Kerala Patrapravarthaka Association (Kerala Media and Journalist Association).