Type writing or Block letter

Attach in this place a recent passport size photograph and sent one auto size photograph for membership card

NEPAL GEOLOGICAL SOCIETY
	P.O. Box: 231, Kathmandu, NEPAL	
	
APPLICATION FORM

For Official Use Only
Application received on _________
Membership granted on _________
Registration No. _______________ 
Membership class _____________	

Membership granted/not granted Reasons for not granting:-	
Renewal Date	Renewed up to		Renewed up to	Bill No.	Signature	Bill No.	Signature	

				

				
To
The President
Nepal Geological Society
Kathmandu, Nepal

I, the undersigned, hereby apply for admission to Life Membership/Membership/Associate Membership of the Nepal Geological Society, and promise to abide by the Constitution and By-Laws of the Society as now formed, or as they may be hereafter legally altered.

Particulars regarding my education, experience etc. are as follows:

A.	PERSONAL DATA
	i) Name (in block Letters) ………………………………………………………………………………..                                                                
		Surname	Name
	ii) Date of Birth …………………………… iii) Place of Birth ………………………………………….                                   
	               	Day/Month/Year 	Place/Country
	iv) Nationality at Birth …………………………………v) Present Nationality ………………………..                    
	
	vi) Address

	   Office……………………………………………………………Tel ……………………………....                 
………………………………………………………………………… Fax………………..…………….
………………………………………………………………………… E-mail ………………………….      
	   Home …………………………………………………………  Tel ………………………………                
              ………………………………………………………………………… E-mail …………………………..             
vii) Blood Group (Optional) :……………………………………………………………………………..	
(Tick mark in box indicates preferred address for mailing)
B.	EDUCATION

Name of the institution	
Period of Study	
Degree
Obtained	
Major field of study	
	From	To			
	Month/Year	Month/Year			

					

	I certify that the statements made by me herewith are complete and true to the best of my knowledge I understand that any willful misstatement renders me liable to expulsion even if admitted to the society.

………………………………			……………………………..	   ………………………
	Signature	    Place	Date

C.	PROFESSIONAL EXPERIENCES

D.	SPONSORS

Name of the Sponsors	Professional position and Organisation	Society Membership Class and No.	Signature & Date	
1.				
2.				

By the decision of the Executive Committee/General body Mr. …………………………………... ………………………………………………is being granted the Membership of the Nepal Geological Society from the date he pays the necessary fees.

Date: ………………………………..                 				…………………………………
					  President/Secretary