[vc_row][vc_column][vc_row_inner][vc_column_inner width=”1/3″][vc_column_text] Student Membership Form Name Father's Name Date of Birth Gender MaleFemaleOther Aadhaar/Voter I Card/PAN No Contact No Email Id Present Address Permanent Address State Pin Name of Institution Contact No Course Undertaking I hereby affirm my allegiance to the constitution of India and undertake to uphold its provision in my personal, official and public life. I hereby certify that all the information furnished with this application are true. I undertake that I will not make use of ACA(Anti-Corruption Academy) for any personal gain nor put its logo and name on my personal letterhead or any other document. In case of violation of the undertaking or any breach og conduct, ACA India will be free to terminate my Membership. I hereby confirm that I am not involved in any Corruption?Criminal cases. I Accept Signature Affix the recent size photograph C-660, New Friends Colony, New Delhi - 110025. Tel: +91-11-4978-5524 B-101, Greenville, Near Lokhandwala Club, Lokhandwala Complex, Andheri-West, Mumbai - 400053. Tel: +91-22-4016-7394 admin@acaindia.net www.acaindia.net [/vc_column_text][/vc_column_inner][vc_column_inner width=”1/3″][vc_column_text] Affix the recent size photograph of the 1st nominee Affix the recent size photograph of the 2nd nominee Membership Applied for Annual MemberLife Member 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& the year of its establishment Whether the applicant's application for membership of this Academy was rejected or withdrawn at any time:If Yes, give details Whether the applicant's applicantion for membership was rejected or withdrawn at any other Academy/ Committee:If Yes, give details Have the applicant or its nominees been charge sheeted for corruption or any criminal act:If Yes, give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 Membership fee 2014 - 15 Category of Member Admission fee Annual fee Lifetime Body Corporate/Institutions INR 10,000 INR 1,00,000 INR 5,00,000 Undertaking We hereby affirm our allegiance to the constitution of India and undertake to uphold its provision in our personal, official and public life. We hereby certify that all the information furnished with this application are true. We undertake that we will not make use of ACA(Anti-Corruption Academy) for any personal gain nor put its logo and name on our personal letterhead or any other document. In case of violation of the undertaking or any breach of conduct, ACA India will be free to terminate our Membership. We hereby confirm that I am not involved in any Corruption? Criminal cases. We Accept Authorised Signatory C-660, New Friends Colony, New Delhi - 110025. Tel: +91-11-4978-5524 B-101, Greenville, Near Lokhandwala Club, Lokhandwala Complex, Andheri-West, Mumbai - 400053. Tel: +91-22-4016-7394 admin@acaindia.net www.acaindia.net [/vc_column_text][/vc_column_inner][vc_column_inner width=”1/3″][vc_column_text] Individual Membership Form Membership Applied for Annual MemberLife MemberHonorary Member Registration Name Father's Name Date of Birth Nationality Address City Postal Code State Mobile Number Home Telephone Fax Email Academic Qualification Professional Qualification, if any Occupation Incase Service, name of the company/Organization Incase Business, nature of Business Office Address Telephone Number Fax If you are 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 application for membership was rejected or withdrawn at any other Academy/ Committee:If Yes, give details Have you ever been charge sheeted for corruption or any criminal act:If Yes:give details Have you 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 Other Information Spouse Details Name of the Spouse Date of Birth Blood Group Occupation I 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 I 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. Date Signature of the Applicant Signature of Proposer Membership No Signature of the Seconder Membership No Membership fee 2014 - 15 Category of Member Admission fee Annual fee Lifetime Individual - Indian INR 2,500 INR 10,000 INR 50,000 - Foreigner USD 100 USD 2,000 USD 10,000 - Student INR 500 INR 2,000 __________ Undertaking I hereby affirm my allegiance to the constitution of India and undertake to uphold its provision in my personal, official and public life. I hereby certify that all the information furnished with this application are true. I undertake that I will not make use of ACA(Anti-Corruption Academy) for any personal gain nor put its logo and name on my personal letterhead or any other document. In case of violation of the undertaking or any breach og conduct, ACA India will be free to terminate my Membership. I hereby confirm that I am not involved in any Corruption?Criminal cases. I Accept Signature Affix the recent size photograph C-660, New Friends Colony, New Delhi - 110025. Tel: +91-11-4978-5524 B-101, Greenville, Near Lokhandwala Club, Lokhandwala Complex, Andheri-West, Mumbai - 400053. Tel: +91-22-4016-7394 admin@acaindia.net www.acaindia.net [/vc_column_text][/vc_column_inner][/vc_row_inner][/vc_column][/vc_row]
