1. Name

2. Sex M/F

3. Date of Birth: day                                    month                                    year                                   

4. Qualifications:

5. Address:                Contact Address                                         Permanent address (in Orissa)
 
 

6. Telephone:                                                 email:

7. Area of interest
 

8. Professional experience
 

9. Type of membership (Please mark; those outside India are expected to take (iv) instead of  (i))

(i) Life members...Rs.1000/-

(ii) Institutional members...Rs.1500/

(iii) Student members...Rs.40/-

(iv) Donor members...Rs.5000/-

(v) Patrons...Rs.25000/-

10. Particulars of payment: Cheque/Draft/Cash (Cheque or Draft payable to OITS). Paid to Treasurer/Secretary/President/Others.

11. Remarks (Please attach a sheet if you would like to give additional information/suggestion.)
 

Signature

Date
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For office use

Membership No.                                           Receipt no.

Remarks, if any

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Cheque or draft in favour of `oits' may be given to Ajit K Behera (m:9437147840), Treasurer, OITS, Silicon Institute of Technology, Bhubaneswar; or, Dr. Dipak Misra (m:9437204685), Secretary, OITS, Xavier Institute, Bhubaneswar or, to Prof S P Misra, President, OITS, 147, Kanan Vihar HIG Colony, Bhubaneswar 751031, and send an email to spmisra1@yahoo.com. Student members shall be accepted only if their activity is managed by their own institutions or chapters, with the membership fees being collected by them for this purpose.