Application for Individual Membership] for Office use only roa 7 rs Member {S354 Indian Concrete Institute No FTsre ok ‘Orson Ces 7, ean Road, Gandhinagar AdyarCh-20. | Please enciose | ype of ESE: Ei Prone : 04-2601 2602421 5996, Telefax: 0-44 245 5148 ‘wo passport size | Member AR) Email :icA@aitelmalin,seogeici@aiteimal in Photos GIES GTR, ctgareialin wrens contro (Fill in BLOCK LETTERS) ate 4. Name in full 2.8 Date of Birth: b Age 3. sox ME] FL] 4. auatincation (PL allach document fr age proof) 5. Status: student Employed Self Employed[—] Retred[_] 6. Organisation : 7. Designation 8 Address : Office Residence City F TOWN ssnnineninnnsnnninennnnnPIl CY TOWN sssinnninnninnninnnnnnninP le Distict District State State Tel Mobil Tel Mobil E-mail E-mail Communicate to: Office [7] Residence [—] 9. Fee Structure: Membership | Entrance + Life Membership Fees Total GST @ 18% | Grand Total Catone (One time Payment) R (Payable) aor Rs. s Rs, | Individual 4,000 + 8,000 (velow 45 years) 9,000.00 1,620.00 10,620.00 11000 + 6,000 {above 45 years) 7,000.00 1,260.00 8,260.00 11000 + 3,500 {above 60 years) 4,500.00 810.00 5,310.00 b [ Overseas erate 25US$ + 275USS 300 US S 410. PaymentDetails: Cash [—] Cheque [_] 00. ‘Amount D.D/Cheque No date érawn on (Cheque / 0.0. to be drawn in favour of “Indian Concrete Institute” payable at Chennai. (OR) Credit to the account of ICI, A/C No.000101208598 in ICICI Bank, Chennai Branch. NEFT J IFSC Code :1C160000001). Page 1 of 2 PTO1" 12. 13. 14, 15) Date Endorsement of ICI Members a. Name Signature Address b. Name Signature Address M.No, M. No, Applicant's Interest in Concrete (Indicate Order of preference a to o) ‘a Conerete Construction b. Reinforcement «. Precast Concrete 4. Prestressed Concrete «8. Structural Interest Nature of Experience Area of Specialization 4. Structural Designs: k. Research & Dev. 49. Special Services |. Concrete Repairs h. Formwork & Moulds m. Concrete Composites i. Concrete Equipment 1. Teg.in Concrete Tech, |. Concrete Testing ©. Others (Please Specify) Contributions to conerete Tech. & construction Signature Remarks (For Office use Only) Secretary General Page 2 of 2