Membership & Insurance

Application Form

Fill in every section marked with *. You can check the progress of your application afterwards with the reference number we give you.

1Personal Details
2Contact Details
3Address in India
4Nominee Details
5Coordinator / Unit
6Declaration

Step 1 of 6

Personal Details

Name, ID and basic identity information

Residential ID Number*

Full Name*

Gender*

Male Female Other

Date of Birth*

Blood Group

Marital Status

Step 2 of 6

Contact Details

Phone, WhatsApp and e-mail

Mobile Number*

With the country code, digits only: 966500000000 (Saudi Arabia), 919000000000 (India).

WhatsApp Number* Same as my mobile number

With the country code, digits only: 966500000000 (Saudi Arabia), 919000000000 (India).

E-mail

Contact Number in India*

With the country code, digits only: 966500000000 (Saudi Arabia), 919000000000 (India).

Step 3 of 6

Address in India

Permanent address (selected from list)

State*

District*

Assembly Constituency

The Niyamasabha constituency of the address in India.

Parliamentary Constituency

The Lok Sabha constituency. Fills itself in when an assembly constituency is chosen.

Local Body*

Post Office*

PIN Code*

House Name*

Place / Village

Step 4 of 6

Nominee Details

One or more nominees; shares must total 100%

Name up to 5 people who should receive the benefit, with shares adding up to exactly 100%.

Nominee 1

Full name*

Relationship to you*

Share*

Date of birth

A nominee under 18 needs a guardian.

Phone

ID proof type

ID proof number

Address

Guardian name

Guardian relationship

Guardian phone

Step 5 of 6

Coordinator / Unit

Who introduced or is handling this member

Coordinator*

Area Committee*

Step 6 of 6

Declaration

Please read this before submitting.

I declare that the information given above is true and complete to the best of my knowledge. I understand that an incorrect or incomplete statement may result in my membership or insurance cover being refused or cancelled, and that a claim may be rejected on that basis.

I consent to Kerala Muslim Cultural Centre storing and processing these details for membership administration, the insurance scheme and the printing of my membership card.

I have read and accept the declaration above*

What is 3 + 4?*

A quick check that you are not an automated script.