Form 1

Education Directorate, National Headquarters,

CIT Campus, IV Cross Road, Taramani, Chennai - 600 113.
 Phone : 044-2254 1102
 Email : [email protected] Website:http//www.csi-india.org

Application for Academic Institution Membership Membership year April-March

You can join CSI online ‘http:// www.csi-india-org’ or

complete this application form and send with payment by post / courier to CSI, Chennai

To For office use only

The Director (Education)
Computer Society of India Membership No.
Education Directorate, National Headquarters,
Receipt No.
CIT Campus, IV Cross Road, Taramani,
Chennai - 600 113. Receipt Date

We hereby apply for academic Institution membership. On approval of Membership, we shall abide by the
Constitution & Byelaws of the Society and the Code of Ethics.

1. Name of the Institution (block letters)

Membership Fees for Academic Institutions :

2. Postal Address (Block Letters) :
(at which mail / other correspondence will be sent) a) Entrance fee : Rs.1500/-
Yearly / Renewal fee : Rs.3000/-
b) The academic institution can nominate three nominees as
members.
c) For additional nominee, yearly fee is Rs.900/-
d) For the membership enrollment during any quarter of the year
the fees payable are :
CITY Period of
Entrance Fees for Fees for
Total
Fees Current Year Next Year
STATE Joining
Rs. Rs. Rs.
Rs.

Phone with STD Code 1st Quarter

1500 3000 Nil 4500
(July to Sept)
2nd Quarter
3. Email: _____________________________________________________ 1500 2250 3000 6750
(Oct ot Dec)
3rd Quarter
1500 1500 3000 6000
(Jan to Mar)
4th Quarter
1500 750 3000 5250
(Apr to June)

e) Long term membership

4. Major Activity of the Institution : Fee Rs. 20,000/- for 7 years (3 nominees are allowed free)
Fee Rs. 55,000/- for 20 years (3 nominees are allowed free)
Entrance fee waived for long term membership.

5. Details of Nominating Authority :

Name Designation

6. Names of the Nominees (3 nominees are allowed free)

Name of the Nominee Membership No. (for CSI use)

1.
2.
3.


 Form 1

7. Subscription / Payment Details (Tick one as applicable)

Entrance Fee Rs. + Subscription Rs. = Total - Rs.

+ =
 Tick one as applicable

DD No. Dated D D M M Y Y for Rs. Bank ___________

Deposit of Rs. ____________________ at Axis Bank SB A/c No. 082010100395144 Branch ___________________

Paid through CSI’s online payment gateway, with Transaction ID: ____________________
Paid through Credit card: ____________________

8. Enter a chapter of choice from the list below :

Region No. Chapter No.

Select your chapter and Region from the List

Region-I Region-II Region-III Region-IV Region-V Region-VI Region-VII
1. Allahabad 11. Durgapur 16. Ahmedabad 28. Balasore 37. Bangalore 45. Aurangabad 54. Calicut
2. Chandigarh 12. Guwahati 17. Bhopal 29. Bokaro 38. Hyderabad 46. Goa 55. Chennai
3. Dehradun 13. Kolkata 18. Chittorgarh 30. Cuttack 39. Mysore 47. Mumbai 56. Cochin
4. Delhi 14. Patna 19. Gwalior 31. Dhanbad 40. New Guntur 48. Nagpur 57. Coimbatore
5. Gaziabad 15. Siliguri 20. Indore 32. Raipur 41. Ongole 49. Nashik 58. Hosur
6. Haridwar 21. Jabalpur 33. Rourkela 42. Vijayawada 50. Navi Mumbai 59. Karaikudi
7. Kanpur 22. Jaipur 34. Ranchi 43. Visakhapatnam 51. Pune 60. Pondicherry
8. Lucknow 23. Mhow 35. Jamshedpur 44. Koneru 52. Solapur 61. Salem
9. Mankapur 24. Surat 36. Bhilai 53. Thane 62. Thanjavur
10. Noida 25. Udaipur 63. Trichy

26. Vadodara 64. Trivandrum

27. Vallabh 65. Vellore

Vidyanagar 66. Annamalainagar

9. Would you like your name to be excluded from the membership lists if given for commercial purpose ? Yes No

10. Code of Ethics : Undertaking :

We affirm that as a CSI member, we shall abide by the Code of Ethics of the Computer Society of India (CSI). we further undertake that
we shall uphold the fair name of the Computer Society of India by maintaninig high standards of integrity and professionalism. We were not a
member of CSI earlier.
We are aware that our breach of the Code of Ethics may lead to disciplinary action against us under the Byelaws and rules of the CSI.
We hereby confirm that we shall be bound by any decision taken by the CSI in such matters.

Place : Date : Signature :

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