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:

Sex:
Male Female

Birthdate:

Approx Birthdate:

Marital Status:

Spouse Details

Spouse Name:

Village:

Father Name:

Mother Name:

Maternal Village:

Birthdate:

Approx Birthdate:

Phone:

Email:

Parent Details:

Father:

Grand Father:

Village:

Mother:

Maternal Village:

Contact

Email:

Phone:

Cell No:

Address

Address Line 1:

Address Line 2:

Country:

State:

City:

Zip Code:

Note: Both references should be members of the LPS of USA.

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

Profile:

Private

Public

Password :

Confirm Password :

Verification Code:

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