JSGA New Member Form

Name of Primary Member*

First NameMiddle NameLast Name

Birth Month of Primary Member*

Birth Year of Primary Member*

E-mail address Primary Member*

example@example.com

Gender*

MaleFemale

Phone Number of Primary Member*

(country-code)+(Area-code)+(phone Number)

Your occupation (optional)

Home Address*

Address Line 1

Address Line 2

City*

State*

zip*

Hometown in India

Do you want to include Address in Member Directory?

YesNo

Marital Status?*

SingleMarried

Childrens (if any)*

None123

Spouse Name*

First NameLast Name

Include Spouse name in Directory ?*

YesNo

Spouse Email Address*

example@example.com

Spouse Mobile Number*

(country-code)+(Area-code)+(phone Number)

Do you wish to provide spouse's occupation information?

YesNo

Spouse Occupation*

Check this box if you wish to include children's information in Member Directory

Child-1 Name*

First NameLast Name

Birth Month

Birth Year

child must be under 21

E-mail address

example@example.com

Mobile number

(country-code)+(Area-code)+(phone Number)

Child-2 Name*

First NameLast Name

Birth Month

Birth Year

child must be under 21

E-mail address

example@example.com

Mobile number

(country-code)+(Area-code)+(phone Number)

Child-3 Name*

First NameLast Name

Birth Month

Birth Year

child must be under 21

E-mail address

example@example.com

Mobile number

(country-code)+(Area-code)+(phone Number)

Does your parents stay with you and/or are dependent on you?

YesNo

Would you like to add parents information to membership directory ?

YesNo

Fathers Full Name

First NameLast Name

Mothers Full Name

First NameLast Name

Father-in-law

First NameLast Name

Mother-in-law

First NameLast Name

Once you submit your details, we will contact you if we have any questions.

Thank you!

Membership charges based on your selection*

Payment is OPTIONAL at this time. Please pay amount due below, if you wish to pay now using Paypal

Note: You should receive an email with total anyways & JSGA Treasurer will send seperate pledge (paid or outstanding) in coming weeks as well.

Thank you for your support to JSGA.

Do you wish to pay online using PayPal. Disclaimer: We do not store any financial information and use secured transaction method.*

YesNo

Paypal charges small transaction fee, would you like to add to the fee?*

YesNo

Final Amount

Total Amount Due (Credit or Debit Card option will be visible on the PayPal login screen on the bottom)

USDFinal amount you will be charged

Pay with PayPal

First Name	Last Name
Credit Card Number	Security Code
Card Expiration

Please click one of the PayPal options to complete payment and submit the form.

New Member Form

Spouse Information >

Children/s Information >

Parents Information >