A.Personal Profile
Name of Company Organization/ Firm
Address
Pin
Please attach a copy of address proof
Tel Off
Fax
Website
Email
(a) Nature of Organization
(b) Nature of Employee
Name, Designation and Address of Nominees(Maximum Four)
1st Nominee
Name
Designation
Address
Pin
Tel Off
Fax
Tel Res
Email
Mobile
2nd Nominee
Name
Designation
Address
Pin
Tel Off
Fax
Tel Res
Email
Mobile
Whether the applicant or its nominees are the member of any other Anti Corruption Academy/ Committee, mention the name of such academy/ committee, address & the year of its establishment
Whether the applicant's application for membership of this Academy was rejected or withdrawn at any time:If Yes, give details
Whether the applicant's applicantion for membership was rejected or withdrawn at any other Academy/ Committee:If Yes, give details
Have the applicant or its nominees been charge sheeted for corruption or any criminal act:If Yes, give details
Have the applicant or its nominees ever been convicted by a court of any offence, whether involving moral turpitude or otherwise, and sentenced in respect thereof to imprisonment: If Yes, give details
We agree to abide by the Memorandum of Association and Rules & Regulations of the Academy as in force from time to time and enclose a cheque/bank Draft No
Dated
Drawn On
For Rs.
(Entrance Fee Rs.
+ Annual Subscription fees
+ Life Membership fees Rs.)
Please attach a copy of PAN Card
We further certify that the above inforamtion is true to the best of my knowledge and belief. The Membership is liable to be cancelled if the information furnished is found to be incorrect.
Signature along with the seal of the company
Name
Desgination
Date
> Signature of Proposer
Membership No
Signature of Seconder
Membership No
