Computer Society of India

Education Directorate, National Headquarters, CIT Campus, IV Cross Road, Taramani, Chennai 600 113. Phone: 044-22541102 / 1103 / 2874 Email: student.membership@csi.india.org Website: http//www.csi-india.org

Form- III
Version 2.4
Membership Year April - March

________________________________________________________________________________________________________

APPLICATION FOR BULK CSI STUDENT MEMBERSHIP (Please fill all boxes in CAPITAL LETTERS)
You can join CSI online http:// www.csi-india.org OR Complete this application form and send with payment by post / courier to CSI, Chennai (Tick one) School Polytechnic

For Office Use Only

: :

Membership No. Receipt No. Receipt Date

College

We hereby apply for opening a CSI student branch at our Institute. On approval of Membership, we shall abide by the Constitution & Byelaws of the Society and the Code of Ethics.

Current Institutional Membership No. (Write Applied if applying now)* *Current Institutional membership is a pre-requisite for opening a student branch. If not a member, also fill in form I and send along with payment to CSI, Chennai 1. Name of the Institution (BLOCK LETTERS)

2. Address (BLOCK LETTERS)

CITY STATE

3. Phone with STD Code ____________________________ 4. Name of the Head of the Institution

(First Name)

(Middle Name)

(Last Name)

5. Designation ______________________________ Mobile : 6. E-mail ______________________________________________

7. Name of the Student Branch Councelor (SBC) : (Must be a faculty Member)

(First Name)
8. Type of SBCs CSI Membership:

(Middle Name)
Individual / Nominee / being nominated now

(Last Name)

9. Membership Number of SBC if already Member 10. Department of SBC_____________________________ Designation of SBC___________________________ 11. E-Mail ID of SBC 12. Mobile
Page- 1

13-a). Student applied for -- WITHOUT copy of CSI Communications (CSIC): No. of years Subscription Amount No. of students Amount Rs. NETT FEES payable to CSI (1) Rs. (2) (3) (2) x (3) Rs.

Form- III

1 2 3 4 1 2 3 4

300 550 750 900 450 700 900 1050 TOTAL Rs.

Total amount Rs._____________

(-) 1/3 share-Rs. _____________ (permitted only if students are >=75) Nett payable to CSI - (A) Rs. _____________

13-b) Additional fee for hard copy of CSI Communications: (DO NOT DEDUCT 1/3 SHARE) No. of years CSIC Charges - Rs. No. of students applying Remitted to CSI, Chennai (1) (2) for hard copy of CSIC (3) (2) x (3)

1 2 3 4 1 2 3 4

250 500 750 1000 375 625 875 1125

Sub-Total (B) Total payable (A) + (B) Rs. Rs.

Payment Mode: (Tick One) DD

Cheque

Direct deposit at Axis bank A/c.

DD / Cheque should be payable at par at Chennai and should be drawn in favour of Computer Society of India Cheque / DD No.____________ dated ____________ for Rs. __________ drawn on _________________________________ (Bank Name & Branch) direct deposit into Axis Bank SB A/c.No.082010100395144 (attach photocopy of Pay-in-slip). Write Institution Name, No of students and Membership No.(if applicable) on the reverse of the Cheque / DD / Pay-in- Slip. Important Note : 1. The Institution should ensure a minimum student strength of 75 at all time and also ensure continued renewal of institutional Membership. 2. One-third of subscription deducted should be deposited in a separate account in the name of CSI - Institution Name Student Branch. This amount should be spent only for conducting events as stipulated for student branches. 3. The SBC is responsible to submit complete accounts for the retained amount and a detailed report of all activities to Director st Education, CSI by 31 March of Each year. 4. Please prepare a soft copy of list of students (Sl.No., Student first name, middle name, last name, email ID, date of birth, subscription period, amount paid) in excel format and send as attachment in an e-mail to student.membership@csi-india.org. 5. A hard copy of this list should be written to a CD and sent along with the application. 6. Please have each student fill in the appended student application form and enclose the bunch to this application. Make additional photocopies as required for all students to fill the forms. 7. Final year and +2 students can take membership only for only one year (April March) 8. On the back side left hand top corner of the Demand Draft / Cheque / Pay-in-Slip, mention Name of the Institute with full address, membership number and total number of Students in the Application Form. 14. Certificate by the Head of the Institute We forward the application for student membership along with soft copy of list of students by e-mail and hard copy (CD) by post. We also forward hard copies of membership application for ________ students who are bonafide students of this Institution.

Signature of the Head of the Institution _______________________ Name : _____________________________

Designation: _____________________________

Date: ________________________

OFFICE SEAL

Computer Society of India

General Instructions:

Form- III

1. The Student membership is available to any student having passed 10 / Matriculation / SSC / SSLC level examination and studying in an approved higher secondary school / polytechnic/College. 2. All information should be filled in BLOCK LETTERS (in English) 3. There is no entry fee. The specified membership fees are subject to review from time to time. 4. Money Orders, Indian Postal Order or Cash will not be accepted for payment of fees. 5. Foreign Student Member subscription fee Yearly US $ 25 6. Student member from College can be enrolled as Associate Member on completion of their studies (UG Degree) by completion of membership upgrade form (Form VI). 8. Membership year is April to March. However student can enroll from any Half year by paying pro-rata fees with minimum one or more year(s) subscription (i.e.) pro-rata fees + fees for one or more years. 9. The pro-rata fee is applicable only if the student opts for current year plus next one, two, three or four years.

th

TABLE 1
Category: Student enrolling during 1 April to 30 September Subscription Only membership without printed copy of CSI Communications Membership with printed copy of CSI Communications (hard copy of CSI Communications cost Rs.250/- per year) One year Rs. 300 Two years Rs. 550 Three years Rs. 750 Four years Rs. 900
st th

550

1050

1500

1900

TABLE 2
Category: Student enrolling during 1 October to 31 March. Subscription Upto 31st March + One year - Rs. 150+300 = 450 375+450 = 825 Upto 31st March+ two years Rs. 150+550 = 700 625+700 = 1325 Upto March 31st + three years Rs. Upto March 31st + four years Rs.
st st

Only membership

without printed
copy of CSI Communications Membership with printed copy of CSI Communications

150+750 = 900 875+900 = 1775

150+900 = 1050 1125+1050 = 2175

Page 3

Computer Society of India

Student Membership Application Form
Tick one -New / Renewal Gender :

Form- III
Male Female

If renewal, enter your Member code: Name Mr./Ms.

With CSIC

Tick one -

Without CSIC

with CSIC

(First Name)
Name of Degree/Diploma/11 /12
Email ID :
th th

(Middle Name)
Branch
(if applicable)

(Last Name)
Semester
(if applicable)

Date of Birth : __ __ / __ __ / __ __ __ __ (DD/MM/YYYY)

From

April

Oct

of 20 ____ to March 20 ________

Mobile :

Subscription paid: Rs .

Respond to the item below only if your membership application is till the end of your final year of study: I am willing to continue my CSI membership as Free Associate Member (FAM) for the next one year on Yes completion of my graduation.

No

____________________________________ Students Signature

---------

CUT HERE FOR ANOTHER STUDENT MEMBER ----------Student Membership Application Form
New / Renewal Gender : Male Female

Tick one --

If renewal, enter your Member code: Name Mr./Ms.

Tick one -

Without CSIC

With CSIC

(First Name)
Name of Degree/Diploma/11 /12th
Email ID :
th

(Middle Name)

(Last Name)
Branch
(if applicable)

Semester
(if applicable)

Date of Birth: __ __ / __ __ / __ __ __ __ (DD/MM/YYYY)

From

April

Oct

of 20 ____ to March 20 ________

Mobile :

Subscription paid: Rs.

Respond to the item below only if your membership application is till the end of your final year of study: I am willing to continue my CSI membership as Free Associate Member (FAM) for the next one year on Yes completion of my graduation.

No

____________________________________ Students Signature Page 4