Welcome to Leuva Patidar Samaj of USA

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MEMBERSHIP RATES
Annual Member	$100
Life Time Member	$1001

Member Details

First Name: *

Middle Name: *

Last Name: *

Email: *

Father: *

Sex:

Male

Female

Mother: *

Village: *

Grandfather: *

Maternal Village: *

Address Line 1: *

Address Line 2:

Country: *

State: *

City: *

Zip Code: *

Phone: *

Cell No: *

Birthdate: * *
Approx Birthdate:

Marital Status:

Spouse Detail

* Spouse Name:

* Village:

* Father Name:

* Mother Name:

* Maternal Village:

* * Birthdate:

Approx Birthdate

* Phone:

* Email:

First Reference

UserName / Email: *

First Name: *

Middle Name: *

Last Name: *

Phone: *

State: *

City: *

Village: *

Second Reference

UserName / Email: *

First Name: *

Middle Name: *

Last Name: *

Phone: *

State: *

City: *

Village: *

Profile:

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Public

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* Confirm Password :

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