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MENSA MembershipAppnFORM
MENSA MembershipAppnFORM
MEMBERSHIP APPLICATION
Name:_____________________________________________________________________
Last name
First name
Middle name
Incomplete forms will be summarily rejected. Photocopies of this form may be used.
Paste
(do NOT staple)
a STAMP size
photo here
OR
Rs. 4530.00 including the Membership Card fee of Rs. 30, towards life membership.
AND
The completed application for membership card along with 3 STAMP-SIZED photographs of
myself
AND
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: _________________________________________________________________
- FOR OFFICE USE ONLY -
Signature
Place:
Date:
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:_____________________________________________________________________