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Address for correspondence :
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PIN CODE______________________
Tel No. ________________________
FAX No. _______________________
E-mail address : _______________________________________
Other Address (Res. / Office) :
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PIN CODE_____________________
Tel No. ________________________
FAX No.________________________
Date of Birth :
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Academic qualifications :
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Award / honours received :
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Present position :
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Fields of specialization :
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Type of membership requested
: Life (Fee: Rs. 500/-) / Institutional (Fee. Rs. 5000/-)
Any particular field in which you would like to contribute : writing articles / giving popular talks / local organization of ILA activities / other (specify)
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Membership payment : Cheque# / Bank Draft No.
Date :
Signature
* Send completed application form along with payment to : General Secretary II, ILA, Laser R & D Block D, Centre for Advanced Technology, CAT INDORE 452 013.
# Make Bank Draft payable to Indian Laser Association payable at Indore. # For outstation cheque add Rs. 30/- for bank charges.
Membership type and No. :
Membership Receipt No. :
Any other remarks :
(General Secretary II)