GUJARAT SAFETY COUNCIL

Midway Height, 4th Floor, Beside Panchmukhi Hanuman Temple,

Near Kirti Mandir, Kalaghoda, Vadodara - 390 001, Gujarat.
Tele : (0265) 2429589, 6596727, Telefax : (0265) 2425202
E-mail : gscouncil@youtele.com, safegujarat@yahoo.in
Website : www.gscgujarat.com

MEMBERSHIP APPLICATION FORM

(Region : Baroda, Surat, A’bad, Rajkot)
To
The General Secretary,
Gujarat Safety Council,
Vadodara.

Dear Sir,

I/We desire to become a member of the Council. The required particulars are provided below. I/we
have read the Memorandum and constitution of the Council and agree to abide by them.

Enclosed herewith please find a Cheque/DD No. dated for

Rs. (Rupees only)
being the amount of Entrance Fees of Rs. and subscription of Rs. for
the year ending March, 20

Your faithfully,

Name

Seal of the Organisation

Designation

FOR OFFICE USE ONLY

Received on GSC Membership No. IO/

Approved on Receipt No.

Approved / Not Approved

Hon. Gen. Secretary

 PARTICULARS FOR MEMBERSHIP
1. Name and address of the Co./Organisation

2. Co./Organisation Telephone No. :

Fax No. :
E-mail :
Website :

3. Year of Establishment

4. Registration number under Factories Act

5. Total No. Of Employees

6. Annual turnover - Rs.

7. Principal Business Activity

8. Name of representative (S) Name Designation Tel. No.

1.

2.

Correspondence to be mailed to
(Write the name of concern person)

Do you have separate Safety Dept. ?

If yes, name of the person incharge

9. Membership Category Industrial Organisation

(Please mark any one)
Employees’ Association
Employers’ Association
Cultural, Social Services,
Educational, Research or
Other Institutions
Life membership (Individual)

10. Do you posses Membership of

any other Safety related
organization ? It yes, name them.

Authorised Signatory

Name

Designation