Website: www.icaiclt.

org
E-mail : calicut@icai.org Tele : (0495) 2770124

CALICUT BRANCH OF SOUTHERN INDIA REGIONAL COUNCIL OF

THE INSTITUTE OF CHARTERED ACCOUNTANTS OF INDIA
CHEROOTTY NAGAR, ERANHIPALAM (P.O) CALICUT-673006

ANNUAL REGISTRATION SCHEME 2019-20

Name : ………………………………….. Membership No ………….…….……....….

Address : Office……………………………. Residence ……………………………..……

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………………………Pin…………………… …………………….Pin …………..……..…....

Telephone No. ……………………………… Telephone No. ……………………..………..

E-mail : …………………………………….. Mob:………………………………………..….

Rs. :………………………………….

Amount in words : Rupees……………………………………………………………………only

Cheque No………………….Bank …………………..………………….…….dated…………....

Transaction reference no. in case of online transfer : …………………………………………..

(Cheque/DD shall be made in favour of ‘CALICUT BRANCH OF ICAI’)

NEFT Details to make online payment

Account Name : Calicut Branch of ICAI

Account No. - 57007555895
Bank - SBI
Branch - Mavoor Road, Calicut
IFSC - SBIN0070561

Date ………………. Signature :