Calcutta Statistical Association, Membership Form

	Calcutta Statistical Association UNIVERSITY COLLEGE OF SCIENCE 35,BALLYGUNGE CIRCULAR ROAD,CALCUTTA-700019
	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 membership fee by Cheque/ Money Order/ Cash.

	Date:
		(Signature)

(Please fill up in block letters)

	Name in full (with titles and degrees)	:
	Residential Address	:
	Occupation and place of Employment	:
	Other particulars	:
	Email ID of Member [ ***In case of online form submission User should supply a valid email ID otherwise form will not be accepted]	:

(For office use)

Form received on: ______________

Subscription received on: ______________

	Proposed by	:
	Seconded by	:
	Date of Election	:
	Membership No.	:

		_____________________
		Signature of the Secretary