MEMBERSHIP NO……………………….. DATE…………………………..

APPLICATION FORM FOR MEMBERSHIP OF

STATE PUBLIC HEALTH ENGINEERS’ ASSOCIATION, WEST BENGAL
To
The Genral Secretary,
S.PH.E.A., W.B

Sir,
I shri …………………………………………………………………………………………. A.E / E.E / S.E /C.E. ……………………………
…………………………………………………under PHE Dte. (Govt. of W.B) do hereby submit my formal application
praying for membership of the Association.

I am enclosing my service particulars & other details in the sheet attached with this application.

Declaration:-
I do hereby affirm that I shall abide by the rules & regulations of the Association & also follow
the programmes & directives as & when be issued by the association time to time.

I do hereby declare that I am not a member of any other similar service Association & I shall not
take membership of any other Association simultaneously.

I also declare that I do not have any lien in service in any other Central / State Govt. Dept. or
undertakings.

I do also hereby declare that I shall be ready to serve the Association in any capacity to the best
of my ability as & when asked for.

In support of the particulars & declarations given by me, I am requesting you to enroll my name in your
Association.

Yours faithfully,

Enclo:- As Stated

…………………………………………………………………
(Full signature of the Applicant)
 SERVICE HISTORY
1. Name of the Officer* :-

2. Designation* :-

3. Present posting* :-

4. Present Basic Pay :-

5. Date of Birth* :-

6. Qualification & Year of Passing* :-

7. Higher studies taken in Service :-

8. Foreign Fellowships /Assignments availed :-

9. Mobile No. :-

10. email id.

(Note:- ‘*’ Mkd. Fields are mandatory)

……………………………………………………..
(Full Signature of Officer)