________________
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 Phone: 727/376-7989
hasmukh33@yahoo.com
ZIP
MONTH/YEAR
Name (please print):
LAST FIRST
MIDDLE Address: STREET
CITY
STATE 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. Your visa status in the USA/Canada?
When did you enter the USA/Canada? What languages do you speak?
____ What is your religion? 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:
Important Considerations: It is important to remember that the MIS is a non-for-profit, voluntary community service. The MIS and JAINA assume no respon-sibility or liability for the accuracy or authenticity of the information furnished in the ads or any consequences resulting thereof. The entire responsibility rests with the candidates themselves. All information furnished to the MIS is confidential. Only those who are sincerely interested in looking for a Jain life partner should send a Registration Form. While matching, photographs will not be passed on to the candidates by the MIS. Parents/guardians should communicate with the candidate before placing ad and assist them in making a final decision.
28/JAIN DIGEST-FALL 2001 Jain Education Interational 2010_02
For Private & Personal Use Only
www.jainelibrary.org
