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
Proposed by : 1.
Name
Membership No.
Signature
2.
Name
Membership No.
Signature
Signature
FOR OFFICE USE ONLY
Application Received
:
Passed on
:
Membership No.
:
Money Receipt No.
:
MEMBERSHIP FEE: ANNUAL : Admission Fee Rs. 200/- +Rs.300/- per year LIFE : Admission Fee Rs. 200/- +Rs.3000/-
List of Documents : Two Copies of recent passport size colour photo Photo ID Proof:(Xerox of any one required) 1. Passport 2. Voter’s ID 3. Driving License 4. PAN Card
Address proof:(Xerox of any one required) 1. Ration Card 2. Latest copy of Life Insurance Policy 3. Latest Electricity Bill 4. Latest Telephone Bill (Landline/Mobile)
All payments must be made by crossed Cheques/ Demand Drafts favouring “Numismatic Society of Calcutta” and should be drawn on/payble at Kolkata. Outstation cheques will not be entertained. Application of Membership is subject to approval of the executive committee