Please affix your

Passport size
photograph. Kindly do
LAXMI NAGAR CPE STUDY CIRCLE not sign or staple the
OF photo.
NORTHERN INDIA REGIONAL COUNCIL
OF
THE INSTITUTE OF CHARTERED ACCOUNTANTS OF INDIA
202, IInd Floor, E-371, Nirman Vihar, Delhi - 110092..
Website : www.lncpesc.com, E-mail : info@lncpesc.com.
Mobile : 9811019657, Office : 011-22521508

MEMBERSHIP FORM

I, hereby apply for Membership of Laxmi Nagar CPE Study Circle and agree to abide by the rules and regulations of
the same as advised by the NIRC of ICAI.

Name : Mr./Ms./Mrs. __________________________________________ COP/Non COP Holder

ICAI Membership No. _____________________ Area of Expertise : ________________________

Date of Birth : ___________________________ Blood Group : ____________________________

Spouse Name : ___________________________ Anniversary date : ________________________

Firm's Name & Office Address : _____________________________________________________

________________________________________________________________________________

________________________________________________________ Pin Code : _____________

Residential Address : _____________________________________________________________

_______________________________________________________________________________

Phone : (O) ________________ (R) __________________ Fax : _______________________

Mobile No. : ________________ Email : _____________________________________________

Amount Paid Rs. _________ (in words) Rupees ________________________________________

Vide Cash/Cheque/DD No. ________ Dated __________ Drawn on ________________________

Branch ________________________________________.

(Signature)
Note : Cheque/DD should be drawn in favour of : `` Laxmi Nagar CPE Study Circle’’.
: Individual Membership Fees for the Calendar Year 2023 – Rs. 2500/-

FOR OFFICE USE

Enrolment No. : ________________________ Receipt No : ____________________________