KARNATAKA STATE LIBRARY ASSOCIATION

# 702, Upstairs, 42nd Cross, III Block, Rajajinagar, Bangalore- 560010

e-mail: secretary@kalaonline.com
(Note: Please fill the form and send it along with DD or Cheque to the above address by post)

MEMBERSHIP FORM
1. NAME

:..

2. DESIGNATION

:..

3. ADDRESS:
Office:

Pin: Telephone:Fax:..
Residence:

Pin: Telephone:..
E-mail:..
4. DATE OF BIRTH

:...

5. QUALIFICATION :

Academic:Professional:
Others:

6. EXPERIENCE
Sl. No.
1
2
3
4
5

:
Institution

Period

Designation

7. For Institutional Membership Only:

7.1 Address of the Institution:
7.2 Contact Person:
7.3 Designation:
Telephone/Fax.No.
8. MEMBERSHIP TYPE (Per Annum)
Life

(Rs. 300/-)

Ordinary

(Rs. 30/-)

*Student

(Rs. 15/-)

Institutional (Rs. 500/-)

Signature
Date:
Note: 1. Enrolment fee of Rs. 10/- (Common for all types of Membership)
2. Please add Rs. 15/- in case of outstation Cheques
3. Cheque/ DD to be drawn in favour of
KARNATAKA STATE LIBRARY ASSOCIATION

* For Student Members

Certified that Sri/Ms................................is a student of
..Course in this Institution.
He/ she may be enrolled as a student member of the Karnataka State Library Association.
Date:
Place:

Signature of the Head with Seal

For OFFICE USE ONLY

Received Rupees (in words) ..Rs..(in fig)

From Sri/Ms..By Cash/DD.
NoDated.and admitted as
a/an..member.
Receipt No.
Dated:
Signature of the Official