LIFE MEMBERSHIP APPLICATION FORM

The General Secretary,                                                          

NATIONAL ORGANISATION OF INSURANCE PENSIONERS

(Regd under Indian Trade Unions Act, 1926, Regn No PN 4769)                             

(Affiliated to Bharateeya Mazdoor Sangh)

BMS Office, Vishwakarma Bhavan, 185, Shaniwar Peth,

PUNE 411 030. Telephone: 020-24454040

Dear Sir,

LIFE MEMBERSHIP APPLICATION FORM

I submit hereby my application for Life Membership of NATIONAL ORGANISATION OF INSURANCE PENSIONERS (NOIP-BMS). I agree to abide by the Rules and Bye-Laws of the Organisation. I place herein below my relevant bio-data.

1. Employee’s full name: Shri/Smt. ………………………………………………………………………..

2. Pensioner’s full name: Shri/Smt. ………………………………………………………………………..

3. Residential Address (with pin code number): ……………………………………………………. …………………………………………………………………………………………………………………………..  …………………………………………………………………………………………………………………………..

4. Telephone No. with STD code: ……………………………   Mobile: ………………………………

5. E-mail id: ……………………………………………………………………………………………………………

6. Date of Birth: ……………………………….. Date of Joining LIC: ……………………………………

7. Date of Retirement: ……………………………………….. Remark if any: …………………………

8. Salary Roll number: ………………………. Pension File number: ………………………………..

9. Last Designation: …………………….. DO/Branch of last posting: ……………………………..

10. Name of Nominee/Beneficiary: ………………………………………………………………………….

11. Relation to the Retiree: ……………………………………………………………………………………..

12. Whether covered under Mediclaim: YES / NO   Amount of cover: Rs. …………………

13. Marriage Anniversary Date: …………………………………………………………………………

I remit herewith the following fees and Donation by CASH /Cheque No. ……………………….

Dated ………………………….. on ………………………………………………..Bank,

……………………………….. Branch

In favour of NATIONAL ORGANISATION OF INSURANCE PENSIONERS For Rs. ……………………..

1.  Admission fee                     Rs.    100-00    

2. Life Membership fee           Rs.    900-00     

3. Annual Postage fee             Rs.       

4. Special Donation                 Rs.    ……………                                   Total: Rs.  …………………….

Thanking you,

Yours faithfully,

Place ………………………  Date …………………………………….

SB A/c No. 520101208632529, IFSC Code- CORP0000445, Union Bank of India, Pimpri-Chinchwad Branch, PUNE

Form may be sent to, Shri Sanjay Ramdasi, Treasurer, NOIP-BMS, (Mob. 07720091685, E-Mail id: ramdasi413@gmail.com), Flat No.2, Plot No.30, Namita Apts, Opp Tata Motors, Chinchwad, PUNE 411 033.