________________
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
FIRST
MIDDLE
Address:
STREET
CITY
STATE
ZIP
Phone:
-
_ Fax: ( )__
Email:
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
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)
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 asume no liability or responsibility for the accuracy or authenticity of the information herein, nor the consequences resulting thereof.
JAIN DIGEST SPRING 1998/31
Jal Education International 2010_02
For Private & Personal Use Only
www.jainelibrary.org
