CSA Membership Form

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Calcutta Statistical Association
UNIVERSITY COLLEGE OF SCIENCE
35,BALLYGUNGE CIRCULAR ROAD,CALCUTTA-700019
E-mail: csa@calcuttastatisticalassociation.org
Application form for Membership

I am in sympathy with objects of the Calcutta Statistical Association and I am desirous of becoming a Member of the Association. I agree to abide by the Constitution and the Rules and Regulations of the Association.
I am sending the sum of ________________________ as my Ordinary/Life membership fees by Cheque on Kolkata Bank or Cash.
Date: ______________ ___________________
(Signature)
(Please fill up in block letters)

Name in full (with titles and degrees)

 :

Residential Address

 :

Corresponding Address

 :

Occupation and place of Employment

 :

E-mail

 :

Phone No
:

(Office)

 (Residence)
Other particulars

 :

(For office use)

Form received on: _____________________
Subscription received on: _______________________

Proposed by
:

Seconded by
:

Date of Election
:

Membership No.
:
_______________________________
(Signature of the Secretary)
 

(Inland Member)
(Foreign Member)
Ordinary Membership feesRs. 250/- US$ 35.00
Life Membership feesRs. 2500/- US$ 350.00
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