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ALL INDIA NIC S&T OFFICERS ASSOCIATION ( Regd.

)
Office : NIC(Hqrs.), A-Block ,CGO Complex, Lodhi Road, New Delhi-110003.

MEMBERSHIP FORM
To,

Pl. affix
one recent
passport
size
photograph

The General Secretary


All India NIC S&T Officers Association
NIC( Hqtrs.), New Delhi-3.
Dear Sir / Madam,

I request you to enroll me as a member of All India NIC S&T Officers Association. My Particulars are given
below:
Name (in block letters) : Mr / Mrs/Ms.___________________________________________________________
Father/Husbands Name:_________________________________________Date of Birth :____/____/________
Employee Code :____________Designation : _____________________________ Blood Group :___________
Date of Joining in NIC : ___/___/______

Date of Superannuation:____/____/_____

Office Address : _____________________________________________________________________________


_____________________________________________Office Phone No.:______________________________
Res. Address ________________________________________________________________________________
____________________________________________Res Phone No. :_________________________________
Mobile No:______________________________ Alternate Mobile No:_______________________________
E-mail: _________________@nic.in

Alternate e-mail id :

Payment details: Amount paid :________ by Cash / Cheque / DD/ NEFT Ref No________________________
dated _____/_____/______ Bank...Branchdated ____/_____/______

Declaration: I do hereby declare that all the information given above are true and correct to the best of my
knowledge and belief. I also undertake that I shall abide by the bye-Laws/rules and regulations of All India NIC
S&T Officers Association .
I hereby authorize DDO to deduct annual fees i.e. Rs 600/- from my salary from April 2015 onwards.
Date: ___/___/20_____

Signature of Member_______________________

One time joining fee is Rs.900/- & Annual Charges Rs.600/-( Rs.50/- per month) Total Rs:1500/- payable by
cash/Cheque/NEFT/ECS favouring All India NIC S&T Officers Association payable at New Delhi
For RTGS/NEFT/ECS: A/C Holder Name All India NIC S&T Officers Association, A/c Number is
037100101029759, IFSC code is CORP0000371 and Branch address is 371 New Delhi Lodhi Complex
Please attach photocopy of NIC Identity Card / Pension Card (for retired persons only).
.... For Office Use
Received Rs....(Rupees....only) by Cash / Cheque / DD No
dated ___/___/____ Bank...BranchReceipt No.dated ___/___/___

Membership accepted : Yes / No

Membership No : Date of Admission : ___/___/______


Authorized Signatory