PATRON MEMBERSHIP

APPLICATION FORM
The Executive Director Date: ……………………….
International Chamber of Commerce (ICC) India
Federation House, Tansen Marg
New Delhi - 110 001

Dear Sir/Ma’am,

We have the pleasure of applying for the Patron Membership of ICC India as also of the International Chamber of
Commerce as per following details:

DETAILS OF THE APPLICANT ENTITY

Name of the Entity …………………………………………………………………………………………………………………..

Address ……………………………………………………………………………………………………………………………….
………………………………………………………………………………………………………………………………………....
City ………………………………………….. State ……………………………........................... Pin ………………………....
Direct Tel …………………………………………………………… Mobile ……………………………....................................
E-mail1 …………………………………………………………… E-mail2 ………………………………………………………..

Address in Delhi (if any) ……………………………………………………………………………………………………………

………………………………………………………………………………………………………………………………………....
Direct Tel …………………………… Mobile …………………………….... E-mail ……………………………………………..

DETAILS OF THE CHIEF EXECUTIVE

Name of the Chief Executive ………………………………………………………………………………………………………

Designation ..……………………………………………………………… Direct Tel ……………………………………………
Mobile ………………………………………………….. E-mail ……………………………………………………………………

ASSOCIATES

Together with our Associates:

1. ………………………………………………………… 3. …………………………………………………………
2. ………………………………………………………… 4. …………………………………………………………
{Fill in the name/s (with address) of Associate/s, if any, not exceeding 4 in number}

NATURE OF BUSINESS

Manufacturing Trading Banking NBFCs Law firm

Construction Hospitality Finance Insurance Marketing
ICT Education Auditing Pharma FMCG
Research & Transport Financial Printing & Digital
Consultancy & Logistics services publishing solutions

Any other (please specify) ……………………………………………………………………………………………………….

Main Line of Business: ……………………………………………………………………………………………………………..

………………………………………………………………………………………………………………………………………...
DETAILS OF THE NOMINEE

We nominate Mr./Ms./Dr./etc. ………………………………………………………………………………………………………

Designation ..……………………………………………………………………… as our representative on the Committee of
ICC India.

All communication to him/her may kindly be sent at:

Address ……………………………………………………………………………………………………………………………….
………………………………………………………………………………………………………………………………………....
City ………………………………………….. State ……………………………........................... Pin ………………………....
Direct Tel …………………………… Mobile …………………………….... E-mail ……………………………………………..

We agree to abide by the Memorandum and Articles of Association.

We are sending herewith a payment of INR 2,00,000/- being the annual subscription which, in our opinion, is payable
according to the Articles of Association and request you to place our application before the Committee of the ICC India
at the earliest and look forward to receiving your acceptance of the same. The mode of payment is:

Cheque/Demand Draft in favour of ICC India, bearing No. ……………................. dated …………………….

RTGS/NEFT/UPI with reference No. …………………………………………………. dated …………………….

Yours truly,

Date Name and Designation Signature of Applicant

All payments should be made via Electronic Transfers like RTGS/NEFT/UPI or by a Cheque or a Demand Draft
favouring ICC India and payable at Delhi.

 As an ICC India member, I/my organization agree(s) that all rights in any rules, codes, papers, reports, training materials, or
other works produced by ICC commissions, task forces or other groups are collective works initiated by ICC/ICC India in which
ICC/ICC India holds all rights. I/my organization further agree(s) that any individual contributions that I/any representative of my
organization may make to such works will not give rise to any rights in such collective works. Additionally, ICC India may further
share the above information with ICC.

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Please send the duly filled application form to:
The Executive Director
International Chamber of Commerce (ICC) India
Federation House, Tansen Marg, New Delhi - 110 001
Tel: 011 23487375 (D)/ 23738760-70 (11 lines) | Fax: 23320714/ 23721504 | E-mail: iccindia@iccindiaonline.org