INDIAN GEOTECHNICAL SOCIETY

INDIAN GEOTECHNICAL SOCIETY
COIMBATORE CHAPTER
DEPARTMENT OF GEOTECHNOLOGY, CIVIL ENGINEERING
GOVERNMENT COLLEGE OF TECHNOLOGY, COIMBATORE – 641013
Email: [email protected] Ph.No. 0422 2432221(322) Fax No. +91 422 2455230
Application for Life Membership
(Please strike out whichever is not applicable)
Full Name, in Block Letters
Technical Qualifications
Date of Birth
/
Member of IGS already
Yes / No
/
Gender
Male / Female
Membership No., if yes
Designation
Address of the organization
Pin
Mobile No.
Email id
Other contact details, if any
Postal
address
correspondence
for
Pin
Membership fee to be paid is ` 1,000/- in favour of ‘IGS Coimbatore Chapter’
Amount `
/-
Cash/Cheque/DD Cheque/DD No.
Issued Bank
Date
Place
Signature of the Applicant
-------------------------------------------------- To be filled by the introducer-------------------------------------------------
Introduced by
IGS Membership No.
Signature
---------------------------------------------------- For IGS Office use only ----------------------------------------------------
An amount of ` _______ /- only received with thanks vide Cash/Cheque/DD No. ____________
from ______________________________________ is accepted as life Membership Fee as
recognized as a life member of IGS with Membership No. ______________________
Secretary, IGS Coimbatore Chapter

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