Name:   Age / Date of birth:   Present Address (with Phone) :   Permanent Address (with Phone & E-mail) :  I am interested in becoming a member because  I am a relative of patient who is my :   A professional (Specify):   Any other reason:   I have learned about Alzheimer's Disease from:   I am interested in Dementia :   Care Support :   I am prepared to  :   Help in the growth of the chapter   Work as a volunteer   I am enclosing :  Life Membership --------Rs.2000 Overseas Membership---------$100 Corporate Membership---------Rs.10000 Chose any   Place:    Date :