MEMBERSHIP FORM

[ TO BE FILLED IN BLOCK LETTERS]

Please Affix
your recent
photograph

Membership Fees : Rs. 1800/- per annum

Entrance Fees (For first time members - one time payment) : Rs. 500/-

Full Name :
Surname first
Date of Birth and Place :
INDos No.: Marital Status : Married Unmarried
C.D.C. No.: Place of Issue : Issued on : Expires on :
Passport No.: Place of Issue : Issued on : Expires on :
Certificate of Competency (COC) No.: _________________________ Place & Date of Issue :
Name of your present company :

Present Rank : Employment Code No. :

Particulars of your last company :

Residence Address :

Landline Nos. :
Mobile Nos. : Spouse / Next of Kin
Email Address :
Details of Next of Kin declared by you at the time of joining the Company
Sr.
No. Full Name Relationship Mobile & E-mail ID
1

The details are required to assist you in case of contingency and/or in case of emergency.
I will be abide by the rules and regulation of constitution of the Union, I agree, undertake and confirm that all agreement/s entered and
or executed by MUI towards representation of its members shall be binding and enforceable by/upon me and accordingly, I authorised
MUI to directly collect my membership fees through my employer.
I therefore request you to enroll me as the member and/or renew my membership of the The Maritime Union of India.

Date : Place :
Signature of Applicant
COC Protection is extended to fully paid up members only. Certificate protection fees of Rs.200 (Rupees Two Hundred only) per year
payable on or before renew date.

FOR OFFICE USE

Membership No.: Amount Received Receipt No.

Place :
Signature of the Authorised Signatory