‘lease fil-up the form in duplicate Additional Page The Institution of Engineers (India) 8 GOKHALE ROAD, KOLKATA 700 020 Tel No. (81)033) 2228-8311/14/15/1603394, Fax No. (1038) 2223-8345, E-mal : membership@lendia org (Membership Application Form) Original Name in Capitals [Surname] [Remaining Name} Specimen Signature —> (* in English only) Passport or stamp size photograph to be pasted here (do not sign on the The signature should not touch the box Photograph) (Use black ink only) Signature * Attested * In case of regional language, signature attestation is a must by a Gazetted Officer with Seal Supporter : Verified the photograph and signature of the applicant ‘Name (in Capitals) Membership No. ‘Signature (in English only) with date 1 FIA Note : The Photograph and signature are to be verified by one of the supporters who will sign the membership application form. -7-%& The Institution of Engineers (India) 8 GOKHALE ROAD, KOLKATA 700 020 TeANo, (91033) 2223-8311/1415/18C4994, Fax No. (21)033) 2223-8345, Eaal : membership@jeintia org (Membership Application Form) Duplicate Name in Capitals [Surname] [Remaining Name] Specimen Signature —> (# in English only) Passport or stamp size photograph to be pasted here (do not sign on the The signature should not touch the box photograph) (Use black ink only) Signature * Attested * In case of regional language, signature attestation is a must by a Gazetted Officer with Seal ‘Supporter : Verified the photograph and signature of the applicant ‘Name (in Capitals) Membership No. Signature (in English only) with date 1 FIWVAM Note : The Photograph and signature are to be verified by one of the supporters who will sign the membership application form.