Charotar Leua Patidar Samaj (CLiPS)

Charotar Leua Patidar Samaj (CLiPS)
Charotar * Kanam * Vakad * Daskoshi
(A non-profit Corporation established in 1990 - Federal ID #77-0264896)
105 Serra Way, #458, Milpitas, CA 95035
MEMBERSHIP UPDATE FORM
Primary Member's Name
(Head of the Family)
First
Middle
Last
Current Address
City
State
Zip Code
E Mail
Native Patidar Gam
Phone (Home)
Spouse’s Name
Region/District
(Bus)
Spouse’s Native Gam
• Charotar (Kheda)
• Kanam/Vakad (Baroda)
• Daskoshi (Amdavad)
Occupation of Primary Member
Spouse’s
Other Family Members LIVING with You (Use extra sheet if needed):
First Name
Birth Date
(Mo/Yr)
Married
(Yes/No)
Relation to Primary
Member
Occupation
Life Member and Annual Member must be a Patidar from Native Charotar, Kanam, Vakad or Daskoshi regions from Gujarat, India.
Life Membership and Annual Membership of a qualified Patidar Family includes Primary Member, his/her spouse, unmarried children, and
parents living with the family as a one family unit. If a member's brother or sister is 21 years or older, they will not count as part of member’s family.
They should become individual CLiPS member. The only exception to this is if the person is disabled.
Patron Membership includes anyone other than a qualified life/annual member(s) as defined above who is a friend and supports the CLiPS
Samaj goals and objectives with limited rights and privileges per the Samaj by-laws. Patron can be a single entity, business or an individual and
his/her spouse and children living with the Patron.
* Children 2 and under are Free
** If you are applying as a single member, then you cannot add any additional members ** (Note: Membership cards will be mailed to you)
*** Annual Membership is from January 01 through December 31 (calendar year).
I hereby apply for the membership of the Charotar Leua Patidar Samaj (CLiPS) and pledge to abide by all
the Articles of Incorporation and by-laws of the CLiPS, also known as (AKA) the Patidar Samaj. Neither the
Patidar Samaj or its board members including trustees nor the facilities rented by the Samaj is liable for any
kind of personal and/or property damages to me or any of my family members or (invited or uninvited)
guests.
FOR SAMAJ USE ONLY
Life Membership/Annual
Membership/Patron
No. ___________________
Amount: $______________
I certify that the information supplied above is correct and complete to the best of my knowledge. I also, Date: _________________
authorize the Patidar Samaj to release and publish the above family information in any future Patidar Samaj
Cash/Check No. ________
Publication(s).
Approval by CLiPS Officer
Applicant’s Signature
Spouse’s Signature
Date
Please mail the completed form to the above CLiPS address or give it to any Board Member