At:-Jagda Main Road,Plot No:-138/909 & 138/1504 ,Po:-Jhirpani. (Near Sarana Chowk),Ps:- Jhirpani,Dist:- Sundargarh, Rourkela- 769042
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Name of Chairman's & Members
Name & Designation Father’s
Name
Address Mobile
No.
UID No. Whether member
of any other society/trust/
company
If answer of column 6 is yes, please furnish details