Numismatic Society of Calcutta (Registered under the West Bengal Societies Act, 1961) Space No. 02-39B, Hudco Building, 2nd Floor, 15N, Nelie Sengupta Sarani, Kolkata - 700 087. web: www.nsckolkata.com, e-mail:nsckolkata@yahoo.com
Membership Application Form Dated
No.
Important Note : Please fill the form in CAPITAL letters, Sign in BLACK Ink.
To The Hony. General Secretary Numismatic Society of Calcutta Kolkata-87 Dear Sir, I hereby apply for Membership of the Society for PATRON LIFE ANNUAL category. I abide by the rules and regulations of the Society, and all the rules/ regulation of our country.I solemnly declare that no criminal / civil proceeding is pending in my name in any court of law. Name: Mr./Mrs./Ms./Dr. First
Middle
Last
Father’s / Husband’s Name Date of Birth: (yyyy/mm/dd)
/
Qualification
/
Nationality Occupation
Permanent Address Pin Code Correspondence Address Pin Code Phone Number
Mobile Number
Email id Identification Document No. Address Proof Document Areas of intrest in Numismatics
Enclosed herewith CASH/ CHEQUE for Rs. Dated
Cheque No. on