________________
MIS REGISTRATION FORM - PAGE 1
Send this completed form, a check in the amount of $25 and a recent, full-length photograph of yourself with your name printed on the back to:
Hasmukh M. Shah, 8721 Scrimshaw Drive,
New Port Richey, FL 34653-6623
Name (please print):
LAST
MIDDLE
Address:
STREET
STATE
Phone: (
)
__ Fax: ( ) -
E-mail:
Date of Birth:
Height:
Weight:
Are you a vegetarian? YES NO
Do you smoke? YES NO
Do you drink? YES NO
Have you been married before? YES NO If yes, indicate the name of your divorced spouse. _
What is your Visa status in the USA/Canada?
When did you enter the USA/Canada?
MONTH/YEAR
What is your religion?
What languages do you speak? What languages do you read? What languages do you write?
Education:
DEGREE
YEAR RECEIVED
MAIOR
NAME OF UNIVERSITY/COLLEGE
Work experience:
COMPANY'S NAME
POSITION
DURATION
Father's Name:
Occupation:
Mother's Name:
Occupation:
Brother(s) and/or Sister(s) –
NAME(S)
AGE(S)
EDUCATION
OCCUPATION
Do you have other relatives living in the North America?
NAME
RELATIONSHIP
OCCUPATION
ADDRESS
Other relevant information (use additional paper if necessary):
Candidate's signature:
Date:
The MIS and JAINA assume no liability or responsibility for the accuracy or authenticity of the information herein, nor the consequences resulting thereof.
JAIN DIGEST WINTER 1997/31
www.jainelibrary.org
in Education Intemational
For Private & Personal Use Only
