For Office use only

Membership No:

APPLICATION FORM FOR MEMBERSHIP

PEFAA
PERADENIYA ENGINEERING FACULTY ALUMNI ASSOCIATION

1. Personal Details

Title (Prof/Dr/Mr/Mrs/Miss/Ms)

Family Name

Date of Birth (dd/mm/yyyy)

Other Names
Designation

Organization

Official Address
Telephone Number
Residential Address
Telephone Number
Preferred Mailing Address ( Home/Official)

Would you allow your personal details to be published on the PEFAA

official website?

Email Address

Fax Number

2. Qualifications
Period of Association with the Faculty
From (dd/mm/yyyy)

To (dd/mm/yyyy)

Type of Association with the Faculty

Undergraduate/Postgraduate/Academic Staff/Non-academic Staff:
Degrees/Qualifications Obtained form the Faculty (if any)

Year of Award

Other Qualifications

Key Areas of Specialization

3. Subscription
Amount Paid

Mode of Payment
Cash/Money Order/Cheque/Bank Draft

Name of the Bank/Post Office

Money Order/Cheque/Bank Draft No.

Declaration

I certify that the above particulars are true and correct

Date (dd/mm/yyyy)

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Signature

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4. Notes
1. Ordinary membership is not available at present.
2. Life membership (To be paid in one instalment) Rs. 1000/= (Local)/US $ 100 (Overseas)
3. A concession is available for recent graduates to become local life members by paying Rs. 200/= at the time
of application and the remaining Rs. 800/= in two instalments within the next two years.
4. Return the completed from together with the payment to :
Treasurer,
PEFAA,
Faculty of Engineering,
University of Peradeniya,
Peradeniya,
Sri Lanka.
5.Email: pefaa@pdn.ac.lk
6.Website: http://www.pdn.ac.lk/eng/pefaa

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