OF

NOTHERN INDIA REGIONAL COUNCIL

                     OF

THE INSTITUTE OF CHARTERED ACCOUNTANTS OF INDIA

Office: 28/20, East Patel Nagar, New Delhi-110008

Tel: +91 9810833994

Ph: +91- 011 25825254

E-mail: Info@Pnsc. In

MEMBERSHIP APPLICATION FORM FOR INDIVIDUAL

I hereby apply for membership of the study circle and agree to abide by the rules and regulations of Patel Nagar CPE Study Circle as implemented by the NIRC of ICAI

(PLEASE FILL UP THE FORM IN BLOCK LETTERS ONLY)

1 Name…………………………………………………………………………………………

2 Date of Birth ……………………………… Date of Anniversary………………………….

3 Firm’s Name …………………………………………………………………………………

4 ICAI Membership No………………………………………………………………………..

5 Office Address…………………………………………………………………………….....

   ………………………………………………………………………………………………

6 Residential Address………………………………………………………………………….

   E-mail…………………………………………………………………………………………

   Phone (O)…………………………(R)……………………………..(M)……………………

7 Amount Paid Rs………………………..(In Word)…………………………………………..

   vide Cash / D. D. / Cheque No………………………………….Date……………………….

   Drawn on………………………………………………….Branch…………………………..

     Note: Cheque/ P.O/D.D.Should be drawn in favour of: “PATEL NAGAR CPE STUDY CIRCLE”

             : Please write your Name & Membership No. on the back of Cheque / P.O. / D.D.

         Participation Fee (other than members of our study circle) for each seminar is   

        Rs.1300/-

       : Membership fess Rs. 3500/- for Single Member. (For First 10 Member Only

        Rs 4000/- thereafter for next 10 members)

      : Kindly provide your e-Mail ID Compulsorily.                          

 Specimen Signature:

(1)                                                                                                                                                      (2)                                              

                                                            FOR OFFICE USE                                                       

Enrollment  No…………………………………………………Receipt No………………….