1.  Name (Block letters)                                  : …………………………………………….
     (Family name first)

2.  Date of birth                                             : …………………………………………….

3.  Academic qualifications                           : …………………………………………….

4.  Designation/Affiliation                             : …………………………………………….

5.  Correspondence address:

                                              Present            : …………………………………………….

                                  …………………………………………….

                                  …………………………………………….
        
          Permanent       : …………………………………………….

                                  …………………………………………….                                        
                                              …………………………………………….

6.     E-mail ID/Tel. No./Mobile No./Fax         : …………………………………………….

                                                                      …………………………………………….

7.     Present field of specialisation               : …………………………………………….

8.     A brief life sketch (professional)              : …………………………………………….

      (use separate sheet, if necessary)              …………………………………………….

                                                                     …………………………………………….

9.     Membership category                           : …………………………………………….

10.   Particulars of payment*                         : …………………………………………….

                                                               …………………………………………….

Date:

Place:                                                                                 Signature of the applicant

Signature

(Member supporting the application)

                                                                      ISEG membership no. LM/M:…………

*by Bank Draft in favour of “INDIAN SOCIETY OF ENGINEERING GEOLOGY”,
payable at Lucknow

Duly filled-in application form, along with payment, may be sent to:
Secretary,Indian Society of Engineering Geology
C/o Director, Monitoring Division (Engineering Geology)
2nd Floor, Geological Survey of India, 27, Jawahar Lal Nehru Road, Kolkata 700 016
e-mail: india.seg@gmail.com