Institute of Actuaries of India

SUBSCRIPTION RENEWAL FORM 2011-12

Please paste one passport size photograph and attach one more and write your name and M. ID on backside of photograph

It is necessary that all the information is provided Country of Residence Member Id:
Full name in capital letters (starting with surname): Class of membership: Associate Affiliate Male Office Address: Female Date of Birth (mm/dd/yyyy) Residential Address Student Fellow

Pin code: Landmark: Address for Correspondence Office Residence Fax number,if any:
Office Telephone(with STD code)

Pin code: Landmark: Email (primary): Email (alternate):

Note: Email id compulsory, as all future communication will be by email

Residence Telephone

(with STD code)

Mobile No.

Annual Subscription Fees Details: Class of Membership Resident in India and other SAARC member Countries (INRs.) Fellows and Affiliates 2,000 Associates 1,000 Students 500

Resident in rest of the world (US $)

140 100 70
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302, Indian Globe Chambers,142, Fort Street, Off D N Road, Mumbai - 400 001 Tel : 022 6784 3333 Fax: 6784 3330. Email:- actsoc@actuariesindia.org

Institute of Actuaries of India

Mode of payment: The annual subscription may be paid by Demand Draft / Pay Order or at par cheque, drawn in favour of Institute of Actuaries of India, payable at Mumbai. Please indicate your full name, Class of membership (Fellow, Affiliate, Associate or Student) & Subscription for the year (mention year) at the back side of DD/Pay Order and on Renewal Form. Please ensure that payment by cheque is honoured by your bank as dishonour of cheque may lead to disciplinary action.

Total Amount paid in Rs. Bank DD/cheque No:Drawn on:- Bank

:Date

Declaration to be made by Affiliate and Fellow members admitted as such based on Fellow membership of another IAA Full member Association: I declare; 1 - that I have not been subject to disciplinary action, either pending or concluded by the Association based on whose fellowship I was admitted as IAI member (in case this is not true please provide the details.) 2 I have paid all dues that are due to the Association based on whose fellowship I was admitted as IAI member. Date: Place:

Signature of Applicant
(within the box)

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302, Indian Globe Chambers,142, Fort Street, Off D N Road, Mumbai - 400 001 Tel : 022 6784 3333 Fax: 6784 3330. Email:- actsoc@actuariesindia.org