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APPLICATION FOR MEMBERSHIP

[ADMISSION TO THE MEMBERSHIP WILL BE SUBJECT TO THE


DECISION BY GOVERNING COUNCIL OF PUNE INTERNATIONAL
CENTRE(PIC)]

Class of Membership applied for: Life

PARTICULARS OF THE APPLICANT

1. Name: ______________________________________________________

2. Date of Birth: _________________________________________________

3. Address
Present:
____________________________________________________________
____________________________________________________________
____________________________________________________________
Permanent:
____________________________________________________________
____________________________________________________________
___________________________________________________________
Office:

____________________________________________________________
____________________________________________________________
___________________________________________________________

Designation:_________________________________________________

Telephone No:
(O)_______________ (M) _______________ (R) ________________

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Email ID:________________________

4. P. A./E.A./Secretary ( Where applicable)


a. Name : ________________________
b. E-mail : ________________________
c. Phone: (o)________________________ (M)__________________

5. Educational Qualifications:
____________________________________________________________
____________________________________________________________
____________________________________________________________

6. Professional Qualifications:
____________________________________________________________
____________________________________________________________
____________________________________________________________

7. Association with professional / social organizations and achievements:


____________________________________________________________
____________________________________________________________
____________________________________________________________

Please feel free to attach additional one pager of personal


achievements& professional qualifications along with this application
form. Also, we strongly encourage you to kindly attach a profile (CV)
if you like.

8. Areas of interest:

▢ Public affairs ▢ International Relations


▢ Science & Technology ▢ Management & Industry
▢ Medicine & Public Health ▢ Agriculture
▢ Environment & Bio Diversity ▢ Education
▢ History & Heritage ▢ Literature
▢ Culture, Films & Theatre ▢ Music, Performing & Fine Arts
▢ Defense / Security and ▢ Any other
Strategic Issues

Date: Signature of the Applicant: ………………….

Place: Name of the Applicant…………………..….

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9. Comments of Proposer (PIC Founding Member/Trustee)

(For how long do you know the applicant, in what way will the applicant be
able to enhance image of PIC even further and in what areas would you think
she/he will be able to contribute towards the objective/ activities of PIC)

____________________________________________________________

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____________________________________________________________

____________________________________________________________

____________________________________________________________

____________________________________________________________

____________________________________________________________

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____________________________________________________________

____________________________________________________________

Proposed by: Seconded by:


Name: Name:

Signature: Signature:

(PIC Trustee/Founder Member) (PIC Member)

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