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    ICC Membership Form

    Uploaded by

    ANIL
    VV

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    ICC Membership Form

    Uploaded by

    ANIL
    6 views2 pages
    VV

    Copyright

    © © All Rights Reserved

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    PDF, TXT or read online from Scribd

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    VV

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    6 views2 pages

    ICC Membership Form

    Uploaded by

    ANIL
    VV

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 2

    Application form for LIFE Membership

    1. Name ( In Block Letters)


    Last, First , Middle :
    2. Sex Male/ Female
    3. Institution

    4.Designation
    5. Date of Birth ( yy: mm: dd)
    6. Academic Qualification

    7 : Address

    Address ( Office) Address ( Residence)

    State: State:
    Pin code : Pin code:
    Telephone No : Telephone no :
    Fax No ; Fax no :
    Mobile No :
    Email : Email :
    8. Preferred address for communication : Office/ Residence
    9. Professional Experience ( If required, separate sheet may be attached)

    Employer Year Position/ Designation

    Contact Details: Telephone: +91 11 26893955/26892601


    Email: [email protected], [email protected], [email protected]

    10. Specialization : ( Low Temp Physics, Cryogenic Technology, Large Scale Cryo project, Cryo
    facility, Industrial gases, Cryo Instrumentation, Cryo biology/ Cryo Medicine/ Cryo Preservation, )

    11. Brief Description on Specialization : ( Separate sheet may be attached)

    12.Name of two referees from the field of Low temperature physics/ Cryogenics

    i)

    ii)

    13. Payment Details: (Life Membership: Total Rs 1100/-). Payment may be made in Cash/NEFT/
    Draft /Cheque in favour of Indian Cryogenics Council- Delhi.

    Payment Mode Cheque Date Bank Branch Amount


    /DD no
    Cash/NEFT/ DD
    /Cheque

    Bank Account Details for NEFT bank transfer:

    Account Name Indian Cryogenics Council Delhi


    Account No. 10596550960
    IFSC Code SBIN0001624
    Bank Name (in full) State Bank of India
    Branch Name Jawaharlal Nehru University, New Mehrauli
    Road, New Delhi-110067
    Complete branch address Jawaharlal Nehru University, New Mehrauli
    Road, New Delhi-110067
    MICR No. 110002056

    Date : Signature :

    14. Recommendation By ICC

    Application EC Decision Membership No Signature Signature


    Received alloted ( Secretary) ( President)

    Contact Details: Telephone: +91 11 26893955/26892601


    Email: [email protected], [email protected], [email protected]

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