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| Membership Type |
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| Personal Details |
| Name
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| Designation |
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| Date of Birth |
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| Gender |
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| Highest Academic Degree |
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| Office Address |
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| Residential Address |
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| Preferred address for correspondence |
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| Email |
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| Phone Number(O) |
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| Phone Number(R) |
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| Fax |
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| Mobile Number |
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| Area of specialization |
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| Payment Details |
| Membership Fee |
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| Reference Number |
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| Terms and Conditions |
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I wish to enroll myself as
member of the ILS. I am paying here with my
membership fee of by Cash/Demand Draft/Cheque (Multi city cheque only)/Online on date .
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Signature of Applicant
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(For Office Use Only)
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| Membership No :
....................
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(Dr. Vinay Sahu)
Signature of Treasurer
Payment Received
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(Gaurav K. Mishra)
Signature of Secretary
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