Numismatic Society of Calcutta

Membership Application Form

No. Dated

Important Note : Please fill the form in CAPITAL letters, Sign in BLACK Ink.

ToThe Hony. General SecretaryNumismatic Society of CalcuttaKolkata-87

Dear Sir,I hereby apply for Membership of the Society for PATRON LIFE ANNUAL category. Iabide by the rules and regulations of the Society, and all the rules/ regulation of our country.Isolemnly 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) / / Nationality

Qualification 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. Cheque No.

Dated on

(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

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. Passport2. Voter’s ID3. Driving License4. PAN Card

Address proof:(Xerox of any one required)1. Ration Card2. Latest copy of Life Insurance Policy3. Latest Electricity Bill4. 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

Proposed by :

1. Name Membership No. Signature

2. Name Membership No. Signature

Signature