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MEMBERSHIP APPLICATION
FILL IN BLOCK LETTERS ONLY
Name: JAGGI AMANVEER SINGH
Last name First name Middle name
Date of Birth (DD-MON-YYYY): 30 June 1997 Blood Group: B+
Membership Type: NEW / TRANSFER Gender: Male / Female
If Transfer, provide all the following details:
Previous chapter: ____________Membership No.: _______________ Membership Type: Annual/Life
Correspondence Address: AATS, TATA GATE, FATEHPUR SIKRI-BODLA ROAD, SHAHGANJ
City: AGRA Pin Code: 282010
Permanent Address: A-72, RAJINDER NAGAR, NEAR SHEEL HOSPITAL
City: BAREILLY Pin Code: 243122
Email: [email protected]
Telephone: ___________(O) ______________ (R) _____________(Mobile) 9536917417
Test Date: 23 FEB 2014 Test Score: _____________Percentile
Current Occupation / Designation: STUDENT
Company/ College/School: DELHI PUBLIC SCHOOL City: AGRA
Interests: READING, SWIMMING
I have enclosed the following:
Rs. 500.00, towards annual membership or Rs. 10,000.00 towards life membership. Fees can be paid in
cash or by a crossed cheque made out to Mensa India Delhi, HDFC a/c no. 00441110000189.
The completed application for membership card along with 3 STAMP-SIZED photographs of myself
A photocopy of my mensa test result, clearly showing my full name and percentile score
OR
A photocopy of life membership proof (in case of transfer for life members only)
Other Interests/Hobbies: _________________________________________________________________
Signature
Place: AGRA
Date: 05 MAY 14
Send to:
Mensa India (Delhi/NCR),
C/o Mr. Kishore Asthana
D-173, Sushant Lok 1
(Opposite HUDA City Centre Metro
Stn)
Gurgaon 122002, Haryana
FOR OFFICE USE ONLY
Membership Type: New Annual / New Life / Transfer Annual / Transfer Life
Documentary proof attached: ____________________________________________
Fees paid: ________ Cash / Cheque / DD: _________dated: ___________ Bank: ________
Receipt Number: _______________________________ dated: ___________
Membership Number: ______________________________________ New / Transfer
Membership Card Status: _______________________________________________________
Comments:___________________________________________________________________
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