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Indian Physics Association: Membership Application Form

The document is a membership application form for the Indian Physics Association. It requests information such as the applicant's name, desired membership type (life, annual, student), date of birth, addresses, contact details, academic qualifications, field of specialization, and payment details. For student applicants, it additionally requires certification of full-time student status from the head of the applicant's department or faculty member.

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Dr. Pradeep Kumar Sharma
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© Attribution Non-Commercial (BY-NC)
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166 views1 page

Indian Physics Association: Membership Application Form

The document is a membership application form for the Indian Physics Association. It requests information such as the applicant's name, desired membership type (life, annual, student), date of birth, addresses, contact details, academic qualifications, field of specialization, and payment details. For student applicants, it additionally requires certification of full-time student status from the head of the applicant's department or faculty member.

Uploaded by

Dr. Pradeep Kumar Sharma
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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INDIAN PHYSICS ASSOCIATION

Affix
Photo

Registration No. BOM. 77/1971 GBBSD, Maharashtra State


Mailing Address: PRIP SHED, ROOM NO. 4, BARC, MUMBAI 400 085.
Email-Id : [email protected] Website : www.ipa1970.org.in

MEMBERSHIP APPLICATION FORM


I wish to become a member of Indian Physics Association, by whose constitution I agree to abide.
1. a. Name:.
(first)

(middle)

(last)

b. Membership desired: Life / Annual / Student


2. Date of Birth : (date/month/year)

Sex :

3. Address (residence) :
..
.. Pin:
4. Address (office) :..
..
.. Pin:
5. a. Mailing Address : Residence / Office

5. b. : email address (if any) ..

6. Telephone (with ISD/STD codes) : Res: Office: .


7. Highest Academic Qualification :
8. Present Position :..
9. Field of Specialisation :
10.Any other Relevant Details :
A DD/Cheque No.....drawn onOR a copy of the
Counterfoil for Direct Money Transfer in favour of IPA MEMBERSHIP Account No. 30970733756 at
SBI, BARC, Mumbai 400085 for the sum of Rs./$......................................towards my Membership Fee*
along with TWO photographs (25 x 35 mm) is enclosed herewith.
*Rs.2000.00 Life Member / Rs.200.00 Annual Member / Rs.100.00 Annual Student Member / US $500
Foreign Life Member / US $50 Foreign Annual Member. All Annual Memberships are offered for the
duration January December. For outstation cheques (outside Mumbai), please ADD Rs. 50/-.
Place : .
Date : ..

Signature

For Student Members only. (student applicants must certify their full time student status)
1. School/Institution :
2.

Signature of Head of the Department / Faculty Member ..

FOR OFFICE USE


Received on
Receipt No .

Membership No.

Secretary (Chapter)
General Secretary (IPA).

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