Request Form for User Registration(Form C)
User Details
User ID purnarogya108Name Sanjay Pisharodi
Gender Male Date of birth 27/07/1973
Designation Doctor Email id [email protected]
Mobile 9947084499 Phone no 04936-243003
Nationality INDIA
Hotel / Guest House / Dharamshala / Institute / Individual House / etc. DetailsName Purnarogya
Capacity 2
Address Dr Sanjay Pisharodi, House number MP XV/24B, Mullankolly P.O, Pulpally, Waynad - 673579
State KERALA City/District WAYANAD
Accomodation type Individual House
Accomodation grade Others
Email id [email protected]
Mobile 9947084499
Phone no 04936-243003
Owner's DetailsName Sanjay Pisharodi
Address H. No. MP XV/24B, Mullalkolly P. O, Pulpally
State KERALA City/District WAYANAD
Email id [email protected]
Mobile 9947084499
Phone no 04936-243003
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _Signature of the Applicant
Date--------------------
Place--------------------
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Name and Signature of Hotel / Guest House / Dharamshala / Institute / Individual House / etc.
Date--------------------
Place--------------------
Registration office address
Office Name : FRO WAYANAD
Address : District Police Chief,Wayanad,North Kalpetta PO
City/ District : WAYANAD
State : KERALA
Pin Code : 673122
Phone Number : 202525
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