Sign Up Form
Note: * Fields are compulsary
Date:*
Name:*
(Mr./Mrs./Miss.)
Last Name*
First Name*
Middle Name
Residential Address:*
City/State:*
Pin:*
Office Address:
City/State:
Pin:
Designation:
D.O.B:*
Please choose your mailing address:
Office OR
Residence
(mm-dd-yy)
Tel no.(Off):*
(Res):
Mobile:*
Email ID:*
Please select your Membership Package and Mode of Payment (all inclusive):
Cash:
Cheque No.:
Bank:
Date:*
Monthly Rs.599/-
Quaterly Rs.1,600/- (Save more than 10%)
Half Yearly Rs.3,050/- (Save more than 15%)
Yearly Rs.5750/- (Save more than 20%)
Gold Membership
Monthly Membership(Dedicated R.M.): Rs.5000/-
Terms and Condition
Please visit
http://www.alaconcierge.com/marketing.php#offer
and go through all our Terms and Condition carefully,tick in the box below and sign.
"I have read Terms and Condition of Home Seva and agree to abide by them."