Online Membership

    ANNEXURE-IV

    APPLICATION FROM FOR MEMBERSHIP

    ODISHA BIGYAN ACADEMY

    Registered under Registration of Societies Act, 1860
    1. Application for: PATRON/LIFE MEMBER

    2. Name in Full:
    3. Date of Birth:
    4. Academic Qualifications (Highes Degree in Science/Technology)

    Degree/Diploma Year Subject Board/University/Institution
    5. Area of Specialization:
    6. Current Interest:
    7. Designation:  
    8. Permanent Address:
    9. Present Address:
    10.Contact Details:

    Telephone No. Land Line: Mobile:
    Email ID  
    11.A brief Outline of Professonal career and scientific activities
    12.Awards/Honours received:
    13.Membership of Academy/Professional Society:
    Proposed by

     

     

    		 Seconded by

     

     

     

     

    Signature

    (Name & Address)

     

     

    Signature

    (Name & Address)
    To,

     

    The Secretary
    Odisha Bigyan Academy
    B/2, Saheed Nagar,
    Bhubaneswar-751007
    Odisha, India
    Dear

     

    I am sending herewith a sum of Rs.___________________/- by Cheque/Draft towards my subscription as a Patron/Life Member for the year______________ Kindly acknowledge the receipt of the Cheque/Draft No.______________________ from (Bank) _______________________ on (Date) _____________.
     

     

    Yours sincerely
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