THE INSTITUTION O.

ENGINEERS (INDIA)
8 GOKHALE ROAD, KOLKATA 700 020

MTIE

INSTRUCTIONS
(for Member Technologist Applicants)

1.0

QUALI.ICATIONS 1.1 1.2 Age : Minimum 32 years on the date of application. Qualification : Having passed graduation degree in Applied Science, Technology, Computer Science and Computer Application or equivalent and having atleast 10 years of employment in aggregate in engineering or industrial profession in a position of responsibility to the satisfaction of the Council of the Institution.

APPLICANTS .OR INDIA AND NEPAL .ee applicable 2.0 AMOUNT TO BE DEPOSITED 2.1 .or Enrolment : Rs. 2900/- payable along with application (Regn. .ee Rs. 700/-, Entrance .ee Rs. 500/- and full Composite Subscription in single remittance Rs. 1700/-) Each journal Rs. 150/- for one and Rs. 700/- for five financial years or part thereof. Option to be indicated (On Line or Print edition) while selecting the Journal.

2.2

.or Journal (Optional)

Note : Journals to the subscribers are available On Line against secured password. Print copies shall be supplied only on specific request. .or secured password please attach the filled-in proforma for password available at www.ieindia.org. 3.0 .ee applicable .or SAARC countries (US $) 150 .or other .oreign countries (US $) 370

3.1 3.2

Payment in single remittance with application .or JournalOptional

Each journal US $ 15 for one and US $ 70 for five financial years or part thereof. Option to be indicated (On Line or Print edition) while selecting the Journal.

4.0 MODE O. PAYMENT 4.1 In Cash at 8 Gokhale Road, Kolkata-700 020 on any working day between 10.00 hrs - 13.30 hrs and 14.00 hrs - 17.00 hrs. Or By demand draft drawn in favour of The Institution of Engineers (India)', payable at Kolkata or by Credit Card as per proforma enclosed. 4.2 PAYMENT BY MONEY ORDER / IPO / OUTSTATION CHEQUE IS NOT ACCEPTED.

NOTE : Details of Bank Draft be mentioned at page no. 1 in the space provided 5.0 ATTESTED PHOTOCOPY O. CERTI.ICATES TO BE SUBMITTED ALONG WITH APPLICATION : 5.1 5.2 In support of date of birth. In support of examination passed.

NOTE : Please see check-list. 1. 2. The photocopy of certificates are to be attested by one of the Supporters of the application. Each information provided by the applicant in the application form must be countersigned by atleast one Supporter.

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For any clarification please contact any one of the following addresses
Agartala : PBNo. 139, Ker Choumuhani, Near Kalibari, Agartala 799 001 Ph : (0381) 2304700, Telefax : (0381) 2223641, E-mail : [email protected] Ahmedabad : Bhaikaka Bhawan, LawCollege Road, Ahmedabad 380 006 Ph : (079) 6400811, Fax : (079) 6561825, E-mail : [email protected] Ahmednagar : Irrigation Compound, Aurangabad Road, Ahmedngar 414 001, Ph : (0241) 2323359 Aligarh : Z HCollege of Engineering & T echnology, Aligarh MuslimUniversity, Aligarh 202 002 Allahabad : T eliarganj, Allahabad 211 004, Ph : (0532) 2545539 Amravati : C/o Cheif Engineer, Maharashtra Jeevan Pradhikaran, Maltekadi, Amravati 444 602, Ph : (0721) 2663225, Fax : (0721) 2663332 Angul : NALCOSmelter & Power Training Institute, NALCONagar, PB No. 30, Angul 759 145 (Orissa) Anpara : 2-RoomField Hostel, ATPS, PO: Anpara, Sonebhadra 231 225, Ph: (05446) 272 885 Extn 654 Asansol : L WOffice Campus, IISCOLimited, Burnpur Road, PO: Burnpur 713 325, Dist : Burdwan, WB, Ph : (0341) 2230809 Aurangabad : Railway Station Road, Osmanpura, Aurangabad 431 005, Ph : (0240) 2325621 Bangalore : 3 Dr B R Ambedkar Veedhi, Bangalore 560 001, Ph : (080) 22264698/ 22207402, Telefax : (080) 22256191, E-mail : [email protected] Barauni : AuditoriumComplex, Barauni Thermal Power Station, At+PO: Barauni Thermal, Begusarai 851 116, Ph : (06243) 65264 / 66348 Bathinda : C/o Shri Vinod Mittal, 66 Veer Colony, Bathinda 151 005 Belapur : Plot No. 106, Sector-15, CB D, Belapur, Navi Mumbai 400 614, Ph : (022) 27579935 Belgaum: Double Road, Shivabasavanagar, Belgaum590 010, Karnataka, Ph : (0831) 470258 Berhampur : At UCPEngineering School, Berhampur 760 010 Ph : (06812) 2205826, E-mail : [email protected] Bhilai : Indira Place, Civic Centre, Bhilai 490 006, Ph : (0788) 2261559 / 898287, Telefax : (0788) 2261559, E-mail : [email protected] Bhopal : Dr MVisvesvaraya Marg, PO: Habibganj, Bhopal 462 024 Ph: (0755) 2506387, Telefax: (0755) 2784572, E-mail : ieimpsc@ sancharnet.in Bhubaneswar : Sachivalaya Marg, Unit IV , Bhubaneswar 751 001 Telefax : (0674) 2400630, E-mail : [email protected] Bokaro : Abhiyanta Bhavan, Sector 5A, Bokaro Steel City 827 001 Ph: (06542) 276227/288972, Fax : (06542) 242099, E-mail : ieibsclc@ yahoo.co.in Calicut : 5/2172A, Saraswatham, Balan KNair Road 1st Lane, Kiliyanad, Ashokapuram, Calicut 673 001 Chandigarh : Madhya Marg, Sector 19A, Chandigarh 160 019 Ph : (0172) 2775418, Fax : (0172) 2540133, E-mail : [email protected] Chennai : 19 Swami Sivananda Salai, Chepauk, Chennai 600 005 Ph : (044) 25360695, Telefax : (044) 25360614, E-mail : [email protected] Cochin: St Benedict Road, Cochin 682 018, Ph: (0484) 2390286/2392661, E-mail : ieikochi@ vsnl.com Coimbatore :PSGT echnology Campus, Peelamedu, Coimbatore 641 004 Ph : (0422) 2578733, Fax : (0422) 2573833 Cuddapah : Prakash Nagar, Cuddapah 516 004, Ph : (08562) 245808 Davangere : Bapuji Institute of Engineering & T echnology Campus, Shamanur Road, Davangere 577 004, Ph : (08192) 222245 / 221461 Dehradun :Opposite Officers Club, Yamuna Colony, Chakrata Road, Dehradun 248 001, Ph: (0135) 2521155 Delhi : Engineers Bhawan, Bahadur Shah Zafar Marg, NewDelhi 110 002, Ph : (011) 23379948 / 23379052, Fax : (011) 23370489, E-mail : [email protected], Website : www.ieidsc.org Dhanbad : Venna Engineers Building, Golf Ground, Dhanbad 826 001, Ph : (0326) 2203626 Dharwad : Balekundry Bhavan, Sir MVisvesvaraya Road, Dharwad 580 001 Ph : (0836) 2742979, E-mail : [email protected] Dibrugarh : PO: Parbatpur 786 623, Dist : Dibrugarh (Assam) Ph : (0374) 2500421, Fax : (0374) 2500317 Durgapur : Nehru Avenue, BZone, Durgapur 713 205, Ph : (0343) 2564770, E-mail : [email protected] Ghaziabad : 15 Shopping Complex, ALTT Centre, Raj Nagar, Ghaziabad 201 002, Ph : (0120) 2728699 Goa : Chimulker House, 2nd Floor, Near Sonali Apartments, Tonca, Caranzalem, Goa 403 002, Ph : (0832) 2463746, E-mail : [email protected] Gulbarga : Court Road, Gulbarga 585 102, Ph : (08472) 429704 Guwahati : Panbazar Overbridge, East Lane, Guwahati 781 001 Ph : (0361) 2548742, Fax : (0361) 2630368, E-mail : [email protected] Hyderabad : Visvesvaraya Bhavan, Khairatabad, Hyderabad 500 004 Ph : (040) 23314969, Telefax : (040) 23314024, E-mail : [email protected], Website : www.ieiapsc.org Indore : SGSITS Campus, 23 Park Road, Indore 452 003, Telefax : (0731) 2434057, E-mail : ieindor@ sancharnet.in Jabalpur : Visvesvaraya Marg, Civil Lines, Jabalpur 482 001 Ph : (0761) 2678929, Fax : (0761) 2545219, E-mail : [email protected] Jaipur : Gandhi Nagar, T onk Road, Jaipur 302 015, Ph: (0141) 2706327 / 2703184, E-mail : ieijpr@ eth.net Jalpaiguri : Jalpaiguri Government Engineering College, Jalpaiguri 735 102, Ph : (03561) 255468 E-mail : [email protected] Jammu : Institution Building, Gandhi Nagar, Jammu 180 004, Ph : (0191) 2439830, E-mail : [email protected] Jamshedpur : Subarnarekha Link, Sakchi, Jamshedpur 831 001, Ph : (0657) 2427982, Fax : (0657) 2437159, E-mail : [email protected] Jodhpur : Residency Road, Jodhpur 342 001, Ph : (0291) 2432708, E-mail : [email protected] Kakinada : J NT UCollege of Engineering Campus, Kakinada 533 003 Kalpakkam: 4th Avenue, DAET ownship, Kalpakkam603 102, Telefax : (04114) 480 068, E-mail : [email protected] Kanpur : Engineers Bhawan, HBTI Campus, Nawabganj, Kanpur 208 002, Telefax : (0512) 2560034, E-mail : [email protected], Website : www.ieikanpur.org Karnal : 1620, Sector-9, UrbanEstate, Karnal 132001, Ph: (0184) 2231202, E-mail : ieihry@ yahoo.com Kharagpur : IIT Campus, Kharagpur 721 302, Ph : (03222) 255221 to 24/277390 to 392 Extn 8047, Fax : (03222) 282700 / 282210 Kolhapur : C/o Executive Engineer, Minor Irrigation Division, Sinchan Bhawan, T arabai Park, Kolhapur 416 003, Ph : (0231) 2650263, Fax : (0231) 2653233 Kolkata : 8 Gokhale Road, Kolkata 700 020, Ph : (033) 22238914, Fax : (033) 22233140 E-mail : [email protected] Kota : Jhalawar Road, Near ESI Hospital, Kota 324 005, Ph : (0744) 2428250, E-mail : [email protected] Lucknow: Engineers Bhawan, River Bank Colony, Lucknow226 018, Ph : (0522) 2225322, Fax : (0522) 2619713, E-mail : [email protected] Ludhiana : Dugri Road, Ludhiana 141 003, Ph : (0161) 2495126 Madurai : 1 Vivekananda Nagar, 100 Feet Road, Surveyor Colony, K Pudur, Madurai 625 007 Ph : (0452) 2561783, E-mail : [email protected] Mangalore : Post Box 23, Panambur, Mangalore 575 010 Mumbai : 15 Haji Ali Park, K K Marg, Mahalaxmi, Mumbai 400 034, Ph : (022) 24942943/24923650, Fax : (022) 24942942, E-mail : [email protected] Munirabad : Sir MVisvesvaraya Centenary Hall, Munirabad 583 233 Muzaffarpur : C/o Muzaffarpur Institute of Technology, Muzaffarpur 842 003, Ph : (0621) 2261918 Mysore : Jhansi Lakshmibai Road, Mysore 570 005, Ph : (0821) 2421168, Telefax : (0821) 2421894, E-mail : [email protected], Website : www.ieimysore.com Nagpur : North Ambazari Road, Nagpur 440 010, Ph: (0712) 2556231/2554387, Fax : (0712) 2525617, E-mail : [email protected] Nashik : PWD(Stores) Campus, Bharat Ratna Sir Visvesvaraya Road, Nashik 422 002, Ph: (0253) 2582500, Fax: (0253) 2350911, E-mail : info@ iei-nashik.org.in, W ebsite: www.iei-nashik.org.in Neyveli : Institution Building, Block 17, Neyveli 607 801, Ph : (04142) 252597, E-mail : [email protected] Palghat : VIII/373 BPL Building, NHBye Pass, Chandranagar, Palakkad 678 007, Ph : (0491) 2573137, E-mail : [email protected] Pantnagar : Post Harvest T echnology Building, College of T echnology (Old), GB Pant University of Agriculture &T echnology, Pantnagar 263 145 Patna: 1942Kranti Marg, Patna800001, Ph: (0612) 2222639/3093203, E-mail : ieibhrsc@ sancharnet.in Port Blair : ALHWComplex, PBNo. 161, Port Blair 744 101, Ph : (03192) 232864/250267/253801, Fax : (03192) 233245/253801 Pune : 1332 Shivajinagar, J MRoad, Pune 411 005, Ph : (020) 25533376, Fax : (020) 25530150, E-mail : [email protected], Website : www.engineerspune.org Raipur : Government Engineering College Campus, Raipur 492 010, Ph : (0771) 2254625 Ranchi : Engineers Bhawan, Nepal Kothi Campus, Ranchi 834 002, Ph : (0651) 2491344, E-mail : [email protected], Website : www.ieijsc.netfirms.com Ranipet : C-65 BHEL T ownship, Ranipet 632 406, Ph : (04172) 2434507 Roorkee : IIT Campus, Roorkee 247 667, Ph : (01332) 284416, Telefax : (01332) 272589, E-mail : [email protected] Rourkela : NIT Campus, Rourkela 769 008, Ph : (0661) 24472709, E-mail : [email protected] Salem: Thiagarajar Polytechnic College, Salem636 005, Ph : (0427) 2447552, Fax : (0427) 2444845, E-mail : [email protected] Saurashtra : 312 Madhav Complex, Dr Yagnik Road, Rajkot 360 001, Ph : (0281) 5523322 Shillong : Barik Point, Shillong 793 001, Telefax : (0364) 2224981, E-mail : [email protected] Shimla : Victoria Place, NigamVihar, Shimla 171 002, Ph : (0177) 2623736 Silchar : Trunk Road, Silchar 788 003, Ph : (03842) 238945, Fax : (03842) 234743, E-mail : [email protected] Srinagar : Sonwarbagh, Near Amar Singh Club, Srinagar 190 001, Telefax : (0194) 2480556 Sunabeda : Post Box No. 11, Sunabeda 763 002 Surat : Mahida Bhavan, Ichchanath, Surat 395 007, Ph : (0261) 2227340, E-mail : [email protected], Website : www.ieisurat.org Tiruchirapalli : BHEL Main Office Road, Tiruchirapalli 620 014, Ph : (0431) 2554285, Fax : (0431) 2520458/2520642, E-mail : [email protected] Tirupati : S V UCollege of Engineering Campus, Tirupati 517 502, Ph : (0877) 2248594, Fax : (0877) 248499 Trichur : TC35/801, Vrindavan, Shornur Road, Trichur 680 001, Ph : (0487) 2321738, Fax : (0487) 2335882, E-mail : [email protected] Trivandrum: 12/33B, Observatory Hills, Trivandrum695 033, Ph : (0471) 2322991, E-mail : [email protected], Website : www.ietvm.org Tuticorin : 1-9/18 Harbour Express Road, Opp to TTPS Camp-1, Tuticorin 628 006 Udaipur : 128 Hiran Magri, Sector 11, Opp Central Excise, Udaipur 313 002, Ph : (0294) 2583702, E-mail : [email protected] V adodara: RaceCourseCircle, Vadodara390007, Ph: (0265) 2310800/2414828, E-mail : tioei@ iqara.net Vallabh Vidyanagar : C/o B V Mahavidyalaya (Engg College), PB No. 20, Vallabh Vidyanagar 388 120, Dist : Anand, Ph : (02692) 230104/230762 Varanasi : Above RoomNo. G-14, 2nd Floor, Institute of T echnology, Benaras Hindu University, Varanasi 221 005 Vijayawada : Dr K L Rao Bhavan, DNo. 29-33-14, Adjacent to Civil Courts, Irrigation Offices Compound, Governorpet, Vijayawada 520 002, Ph : (0866) 2576822 Visakhapatnam: Visvesvaraya Bhavan, Station Road, Visakhapatnam530 016, Ph : (0891) 2747460, Fax : (0891) 2747460, E-mail : [email protected] W arangal : C/o Kamala Institute of T echnology & Science, Singapore, Huzurabad, Karimnagar 505 468

LOCATION OF OVERSEAS CHAPTERS

Abu Dhabi : POBox No. 3967, Abu Dhabi, UAE, Ph : (00971-2) 6349534, Fax : (00971-2) 347282 Bahrain : POBox No. 1724, Manama, Bahrain, Telefax : (00973) 830537, E-mail : [email protected], Website : www.ieibc.com.bh Dubai : POBox No. 50241, Dubai, UAE, Ph : (00971-4) 4-220501, Fax : (00971-4) 4-225869 Kuwait : POBox No. 9554, Salmiya 22096, Kuwait, Ph : (00965) 2448965/2445588/2449072, Telefax : (00965) 2428148, E-mail : [email protected] Qatar : POBox No. 18523, Doha, Qatar, Ph : (00974-4) 4427672, Telefax : (00974-4) 4427673, E-mail : [email protected], Website : www.ieiqatarchapter.com Sydney : suite 100, Level 4, 515 Kent Street, Sydney 2000, Australia Ph: (0061-2) 92679255, Fax : (0061-2) 92679005

CHECK-LIST
(To be returned along with the application form)
Tick out the boxes to check, whether you have filled in/attached the following particulars along with your application : 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. Application is duly signed by the applicant. Form is properly supported by specified number of member (F/M/AM) as required. Draft of Rs. in favour of THE INSTITUTION OF ENGINEERS (INDIA), PAYABLE AT KOLKATA.

Attested Xerox copy of Degree certificate issued by the University duly attested by a supporter of the application. Attested xerox copy of final pass certificate. In case of Provisional certificates, attested xerox copy of Final pass mark-sheet indicating all subjects clearly. Attested xerox copy of documentary evidence in support of date of birth. Attested copy of post qualification professional experience details in chronological order. Experience/career details are duly authenticated by one of the supporters / employer. Choice of Division part of Engineering Journal(s) clearly specified alongwith fee. Signature of the Applicant on the application form, if in any language other than English, must be attested by a supporter of the application.

This check-list will ensure faster processing and disposal of your application. Date ................................. ............................................. (Signature of Applicant) Name ...................................................................................... (In Capitals) Full Address ............................................................................. ................................................................................................ ................................................. Pin Code

Name and Address to be filled in by the applicant

THE INSTITUTION OF ENGINEERS (INDIA)

8, Gokhale Road, Kolkata - 700 020 Name ...................................................................................... (In Capitals) Full Address ............................................................................. ................................................................................................ ................................................. Pin Code

Name and Address to be filled in by the applicant

Acknowledgement-cum-Receipt
(for Office use only) Application Registration No. ........................................................................ Received with thanks a sum of Rs. ............................. (Rupees ................................................................................. ..............................................................................................................................................................................) from the above named applicant towards *Application Deposit/Registration Fee. for Secretary & Director General
*Total of Entrance Fee and Composite Fee. (Please see front page for necessary information and instructions) NOTE : In case a candidate is not eligible for election as member, he/she is eligible for refund of his/her Entrance fee and the amount deposited for composite subscription, without any interest thereon, after deducting non-refundable Registration fee and general office charges as per Regulation.

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IMPORTANT INFORMATION
1. Your application has been duly registered under number mentioned on reverse. Please do not fail to quote your Registration Number and your full name and address in block letters for all future correspondence with this office. Final decision on your application rests with the Council only. This decision is final and binding on the applicant. Any change in address should be intimated to this office without delay, quoting your Registration Number. The application deposit paid by you is adjustable only after the application is finally disposed of by the Council. The application deposit may be paid by demand draft, payable to The Institution of Engineers (India) on any Bank at Kolkata, preferably State Bank of India or by Credit Card or in Cash at 8 Gokhale Road, Kolkata 700 020. As a matter of policy we do not accept any outstation cheque.

2. 3. 4. 5.

6.

THE INSTITUTION OF ENGINEERS (INDIA)

8 GOKHALE ROAD, KOLKATA 700 020 Application for Member Technologist (M.T.I.E.)
for office use only

MTIE

Reg. No.

d d Date

m m

Registration Fee Membership Suspense Life Compounding Fee Composite Journal Fee Miscellaneous

X1500100 V0700200 X0900100 X4000100 X2900100

Rs/Dollars Rs/Dollars Rs/Dollars Rs/Dollars Rs/Dollars

Signature ...........................................................

Division attached

Journal Choice

Deputy Director (Membership)

P.L. No. ...................................... Dated ....................................... Approved for ........................................... Memb. No. ........................................................... Enrolled on .........................................................................

Name in Capitals Encl : Draft no

[First] for Rs

[Middle] Date

[Last]

Bank name (in Capitals) Branch name (in Capitals)

In case of online payment, please quote your Receiving Serial No. here ......................................................................................................

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THE INSTITUTION OF ENGINEERS (INDIA)

8 GOKHALE ROAD, KOLKATA 700 020

MTIE

Last Name* C/o House No Street City

Remaining Name* Country Pincode Tel No (O) Tel No (R) E-mail

State *In Capitals Date of birth Nationality

The Secretary & Director General The Institution of Engineers (India) 8 Gokhale Road, Kolkata 700 020

Mobile Son/Daughter/Wife of .......................................................................................................... Age on Date of Application : Year Abbreviated Qualifications Months

Date ..........................

Dear Sir, 1. I hereby apply for election as a Member Technologist of the Institution of Engineers (India) in accordance with the Charter of Incorporation and the Bye-Laws as they now stand or as they may be legally altered hereafter. 2. I do hereby undertake that in the event of my election as a Member Technologist, I will be governed by the Bye-Laws and the Regulations of the Institution as they now are or as they may hereafter be legally altered and that I will accept as final and binding the decisions of the Council in all matters dealt with by them in accordance with the provisions of the Charter, Bye-Laws and Regulations, and will forthwith cease to describe myself as a Member Technologist or to designate myself as belonging to the Institution in any other form, on receipt of a notice from the Secretary and Director General that acting under the powers conferred upon them by the Bye-Laws and Regulations the Council have declared me to be no longer as a Member Technologist of the Institution. I further undertake that I will promote the objects of the Institution, as far as may be in my power, provided that whenever I shall signify in writing to the Secretary and Director General that I am desirous of withdrawing from the Institution, I shall after the payment of any arrears which may be due by me at that period be free from this obligation. 3. I have noted that the decision of the Council of the Institution shall be final in granting the membership and the District Courts at Alipore, 24 Parganas (South) shall have the exclusive jurisdiction in settling the dispute, if any, arising out of this membership. 4. I accept responsibility for the accuracy of the particulars contained in the application form with regard to my qualification and experience and agree that if I am elected the validity of my election shall depend upon the accuracy of such particulars as required in the Bye-Laws. I also undertake to abide by professional conduct rules and/or Code of Ethics that the Council may frame from time to time. x xxxxxxxxxxxxxxxxxxxxx Yours faithfully,

Encl. Copies of .................... documents. Name (in Capitals) ................................................................................ Signature *Attested * In case of regional language, signature, attestation is a must by a Gazetted Officer with Seel SUPPORTERS

..................................................................... Signature of the applicant (*in English only) Regn. No. Do not write anything within the box (for office use only)

: From personal knowledge of the applicant and in consideration of his/her qualifications as stated on the reverse, we recommend him/her to the Council as being in every way a fit and proper person to be admitted to the Institution as a Member Technologist.

Name (in Capitals) 1 ................................................................................... 2 ...................................................................................

Membership No. F .................................... F/M/AM ..........................

Signature (in English only) with date .................................................................... ....................................................................

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2 of 2
Note : Each information provided by the applicant must be authenticated by a supporter of the application Name of Examination/s Passed Branch of Engineering Examining Authority Full Name and Address of the College Year of Passing

l Present Position

l In the case of Self-employment / Consultant : Please enclose (i) Profile of the Organization, (ii) Value of works (yearwise, in money worth) and (iii) Nature of Projects handled duly attested by a supporter.

Uptodate Chronological Engineering Career Designation(s) of post(s) held Name and address of Employer From (Date) To (Date)

Present Rank, Actual date of Commission and Personal Number (for Military personnel only) :

Details of Professional Career : (a) Most Important Engineering works for which Personally Responsible (Please attach statement duly attested) (b) Research and Teaching Experience (if any) [Please attach statement duly attested] (c) Specialisation (if any) [Please attach sheet duly attested]
Technical Papers Published (if any) [Please attach sheet duly attested as per following format] Title of the Paper Name of Journal in which Published Date of Publication

Membership of other Engineering Institutions/Societies (if any) [Please attach sheet duly attested as per following format]

Name of Institution / Society

Grade of Membership

Date of Election

Whether still a Member

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Authentication by a Supporter

Authentication by a Supporter

Exact Designation

Place of Posting

Full name and address of the present employer

Authentication by a Supporter

Plea s e fill-u p th e form in d u plica te

ORIGINAL

You ca n a ls o p a y t h e d u e a m ou n t b y Cr ed it / Deb it Ca r d

AUTHORIS ATION OF PAYMENT BY CREDIT CARD

AUTHORIS ATION *Cr ed it Ca r d [Tick a s a p p lica b le]

MAS TE RS

VIS A

Plea s e ch a r ge Rs . ........................ a ga in s t Ca r d No. Ca r d E xp ir y Da t e M M Y Y Y Y

Ca r d Hold er s S ign a t u r e .................................................................... Ca r d Hold er s Na m e ........................................................................................................... Ap p lica n ts Na m e ................................................. Mem b er s h ip Gr a d e & ......................... No. [If a p p lica b le] DUPLICATE You ca n a ls o p a y t h e d u e a m ou n t b y Cr ed it / Deb it Ca r d

AUTHORIS ATION OF PAYMENT BY CREDIT CARD

AUTHORIS ATION *Cr ed it Ca r d [Tick a s a p p lica b le]

MAS TE RS

VIS A

Plea s e ch a r ge Rs . ........................ a ga in s t Ca r d No. Ca r d E xp ir y Da t e M M Y Y Y Y

Ca r d Hold er s S ign a t u r e .................................................................... Ca r d Hold er s Na m e ........................................................................................................... Ap p lica n ts Na m e ................................................. Mem b er s h ip Gr a d e & ......................... No. [If a p p lica b le]