Mail to:

mensa india (delhi/NCR),

MEMBERSHIP APPLICATION

c/o Mr. Kishore Asthana

D-173, Sushant Lok 1
(Opposite Park Plaza Hotel)
Gurgaon 122002, Haryana
Tel: 9818148602

FILL IN BLOCK LETTERS ONLY

Name:_____________________________________________________________________
Last name

First name

Middle name

Date of Birth (DD-MON-YYYY): ___________________________ Blood Group: ______

Incomplete forms will be summarily rejected. Photocopies of this form may be used.

Membership Type: NEW / TRANSFER

Paste
(do NOT staple)
a STAMP size
photo here

Gender: Male / Female

If Transfer, provide all the following details:

Previous chapter: _________________________________________________
Membership Type: ANNUAL / LIFE
Membership Number: ________________________________________
Correspondence Address: _______________________________________________________________
____________________________________________________________________________________
City: ______________________________Pin Code: ______________Tel: ____ - __________________
Permanent Address: ___________________________________________________________________
____________________________________________________________________________________
City: ______________________________Pin Code: _______________Tel: _____-_________________
Telephone: ____ - ______________ (O) ____ - ______________ (R) ____________________ (Mobile)
E-mail Address: ______________________________________@_______________________________
I have enclosed the following:
Rs. 330.00, including the Membership Card fee of Rs. 30, towards annual membership,

OR
Rs. 4530.00 including the Membership Card fee of Rs. 30, towards life membership.
AND
The completed application for membership card along with 3 STAMP-SIZED photographs of
myself
AND
A photocopy of my mensa test result, clearly showing my full name and percentile score
OR
A photocopy of life membership proof (in case of transfer for life members only)
Other Interests/Hobbies: _________________________________________________________________
- FOR OFFICE USE ONLY -

Signature
Place:
Date:

Membership Type: New Annual / New Life / Transfer Annual / Transfer Life
Documentary proof attached: _____________________________________________________
Fees paid: ________ Cash / Cheque / DD: ___________ dated: ___________ Bank: ________
Receipt Number: _______________________________ dated: ___________
Membership Number: ______________________________________________ New / Transfer
Membership Card Status: ________________________________________________________
Comments:_____________________________________________________________________