INDIAN SOCIETY OF MECHANICAL ENGINEERS

Plot No. 23-B, Meera Road, Devaraj Nagar, Selaiyur, Chennai600 073. Ph : 044-65372284 E-Mail: ismeinfomembership@gmail.com www.ismeindia.com

APPLICATION FOR PROFESSIONAL MEMBERSHIP

ENGINEERING SPECIALIZATION For Mechanical, Machine Tool, Tool & Die, Production, IEM, Automobile, R & AC, Aerospace, Mechatronics

Membership Required ____________________________________

1. Name (Block letters) 2. Father's Name 3. Nationality 5. Age 7. Sex 9. Religion 10. Present Address

: : : : : Male : : 4. Date of Birth 6. Place of Birth Female 8. Marital Status : Married Unmarried

11. Permanent Address

12. Residence Phone No. 14. E-mail ID : 1) 15. No. of Technical Paper Published

: 2) : Yes No Yes No

13. Mobile No. :

16. Do you require International of Professional Membership :

17. Educational Qualification, Technical, Trade, Vocational, Short-Term Computer Courses & Other Academics : (Please fill the following) Course 10 Years Equivalent 10 + 2 Years Equivalent Diploma Bachelor Degree Master Degree Ph.D Degree University / Board Major / Specialization Year of Passing % Marks

Additional Qualification Obtained : Professional Membership Qualification, Licenses (or) Certificate: Name of the Professional Society Membership Grade Membership No. Validity Date of Award

Technical Training/Industry/Teaching experience : Employer Name (Current) : Designation : Duration of service : Function& Responsibilities :

Declaration : I agree to abide by rules of the Society.

Date :

Candidate Signature

GUIDELINES : l This application form must be completed in capital letters. l Three passport size color photo should be enclosed l Membership processing duration - 90 days l Photocopies of all relevant certificates, training and Experience must be attached. l If there is insufficient space within any section, the applicant may submit additional information on a separate sheet of paper. l Life Time Membership Fee (only Professionals)- Rs.3000/- (Three Thousand only) l Demand Draft must be drawn in favour of Indian Society of Mechanical Engineers payable at Chennai. DD can be taken in any Bank. l Membership Benefits - Refer the Society Brochure l Professional Membership choice will be given as per the engineering specialization. l All documents should be mailed by Courier/Register Post/Speed Post to : Engineering Today Building, Membership Division, Plot No.23-B, Meera Road, Devaraj Nagar, Near Bharat University, Opp to PNB, Selaiyur, Chennai 600073, Tamil Nadu, India. Tel : 044-65372284 Mobile : 09790326929

OFFICE USE ONLY

Membership Grade: 1.Student Member 2.Graduate Member 3.Associate 4.Associate Member 5.Member 6.Senior Member 7.Fellow 8.Senior Fellow 9.Honorary Fellow. 10.Affiliate Member 11.Patron Member. Remarks Membership No. _____________________________________ Date Received _______________________ DDNo_______________________ Bank Name ________________________________________________________________ Receipt No _______________________________ Receipt Book No_______________________ Approved ___________________ Not Approved _______________________Cancelled _______________________ Under Process _______________________Returned_______________________

Date :
PLEASE TAKE PHOTOCOPY IF NEEDED

Executive Committee Sign.

Registrar Sign.