Please Attach a STAMP size

photo here

MEMBERSHIP APPLICATION FILL IN BLOCK LETTERS ONLY

Name: JAGGI AMANVEER SINGH

Last name First name Middle name

Date of Birth (DD-MON-YYYY): 30 June 1997 Blood Group: B+ Membership Type: NEW / TRANSFER Gender: Male / Female If Transfer, provide all the following details:

Previous chapter: ____________Membership No.: _______________ Membership Type: Annual/Life

Correspondence Address: AATS, TATA GATE, FATEHPUR SIKRI-BODLA ROAD, SHAHGANJ

City: AGRA Pin Code: 282010

Permanent Address: A-72, RAJINDER NAGAR, NEAR SHEEL HOSPITAL

City: BAREILLY Pin Code: 243122

Email: aman.jaggi.s@gmail.com

Telephone: ___________(O) ______________ (R) _____________(Mobile) 9536917417

Test Date: 23 FEB 2014 Test Score: _____________Percentile

Current Occupation / Designation: STUDENT

Company/ College/School: DELHI PUBLIC SCHOOL City: AGRA

Interests: READING, SWIMMING I have enclosed the following: � Rs. 500.00, towards annual membership or Rs. 10,000.00 towards life membership. Fees can be paid in

cash or by a crossed cheque made out to Mensa India Delhi, HDFC a/c no. 00441110000189.

� The completed application for membership card along with 3 STAMP-SIZED photographs of myself

� A photocopy of my mensa test result, clearly showing my full name and percentile score

� OR

� A photocopy of life membership proof (in case of transfer for life members only)

Other Interests/Hobbies: _________________________________________________________________

Signature Place: AGRA Date: 05 MAY 14

Send to:

Mensa India (Delhi/NCR), C/o Mr. Kishore Asthana D-173, Sushant Lok 1 (Opposite HUDA City Centre Metro Stn) Gurgaon 122002, Haryana

FOR OFFICE USE ONLY

Membership Type: New Annual / New Life / Transfer Annual / Transfer Life

Documentary proof attached: ____________________________________________

Fees paid: ________ Cash / Cheque / DD: _________dated: ___________ Bank: ________

Receipt Number: _______________________________ dated: ___________

Membership Number: ______________________________________ New / Transfer

Membership Card Status: _______________________________________________________

Comments:___________________________________________________________________

Incom

ple

te form

s w

ill be r

eje

cte

d. Photo

copie

s o

f th

is form

can b

e u

sed.