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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):
FIRST
MIDDLE
Address:
STREET
CITY
STATE
Phone:
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Fax: (
)
Email:
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Date of Birth:
Height:
Weight:
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Are you a vegetarian? YES NO
Do you smoke? YES NO
Do you drink? YES NO
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Have you been married before? YES NO If yes, indicate the name of your divorced spouse.
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What is your visa status in the USA/Canada?
When did you enter the USA/Canada?
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MONTH/YEAR
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What is your religion?
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What languages do you speak? What languages do you read? What languages do you write?
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Education: -
DEGREE
YEAR RECEIVED
MAJOR
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) _
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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):
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-
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Candidate's signature:
Date:
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1
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 SUMMER 1999/37
Jal Education Intemational
For Private & Personal use only
www.jainelibrary.org
