EASTERN INDIA PHILATELISTS’ ASSOCIATION Paste your

(Founded in 1997)
Registered under Societies Registration Act & Affiliate to Philatelic Congress of India Passport Size
Plot No. 969/2436, Forest Park, Bhubaneswar-751009, Odisha
E-mail : eipaodisha98@gmail.com PHOTO HERE
MEMBERSHIP APPLICATION FORM
(Fill details in English in this column & Use CAPITAL Letters)
The Secretary,
Please enroll me/us as a member/Life member/institutional member of the Eastern India Philatelists’
Association. I/we enclose herewith the subscription fee in cash/cheque/DD No...................................
Dt..........................For Rs............................(Rupees................................................................................)

Name.................................................................................................Nationality..........................
Date of Birth......................................................................................Blood Group......................
Address.........................................................................................................................................
............................................................................................................Pin code...........................
Mobile No(a)................................................(b)...........................................................................
E-Mail Id.......................................................Occupation..............................................................
Stamp collecting since when.............................Philatelic Interest...............................................
............................................................................(What items/themes do you collect or deal in).
Other Hobbies...............................................................................................................................
Are you a Philatelic Dealer ......................... (If yes, mention the name of your firm & address)
......................................................................................................................................................
For Institutions: Please state your objectives/activities in brief..................................................
......................................................................................................................................................

Signature of the parent or Guardian Signature of the Applicant

(For Junior member below 18 years) (For Institutional Members affix Seal)

Recommended by...............................................................Membership No................................

Seconded by.......................................................................Membership No.................................
For Office Use Only
Membership No.....................Subscription Received Rs....................Vide Receipt No.........................

Place: Signature of the Secretary

Date:
EIPA