You are on page 1of 2

Submit by Email

INTERNATIONAL INDIAN STATISTICAL


ASSOCIATION
MEMBERSHIP APPLICATION & RENEWAL FORM (2010-2011)

Membership Type:
Select one:

Life

__ Renewal
Annual

__ New
2-year

3-year

Student

Retired

MATHEW
Last Name: ______________________________________________________
ANGEL
First Name/MI: ___________________________________________________
ASSISTANT PROFESSOR
Title: ___________________________________________________________

MAHARAJAS COLLEGE, ERNAKULAM (M.G. UNIVERSITY, KOTTAYAM)


Affiliation: ______________________________________________________
HOUSE, NELLAD P.O., MUVATTUPUZHA,
Mailing Address: VANAKKUDIYIL
_________________________________________________

ERNAKULAM (DIST), KERALA, INDIA, PIN:686669

________________________________________________________________
________________________________________________________________
________________________________________________________________

Work Phone #: +91-9447702030


___________________________________________________
Home Phone #: 0484-2653060
___________________________________________________
Fax #: __________________________________________________________
E-mail: angelmathew@gmail.com
_________________________________________________________
2012-02-15

Signature: ____________________________________ Date: _____________

Reset Form

Print Form

Membership Fees
Regular Membership Dues (Outside India):

Life Membership Fee: $300.00 (US)


Regular Annual Membership Fee: $25.00 (US)
$40 (US) for 2 years and $50 (US) for 3 years
Student Annual Membership Fee: $5.00 (US)

Please write your check (in US funds) to International Indian Statistical Association.
Please return this form with cash/check (in person) or mail your check to:
Subrata Kundu (kundu@gwu.edu)/Sudip Bose (sudip@gwu.edu), Treasurer, IISA
Department of Statistics
George Washington University
2140 Pennsylvania Avenue NW
Washington, D.C. 20052, USA

IISA-India Chapter Dues (Resident Indians only):

Life Membership Fee: Rs. 1500


Regular Annual membership Fee: Rs. 100
2-year membership: Rs. 150, 3-year membership: Rs. 200
Life Membership (Retired): Rs. 500

The Demand/Bank Draft for membership (IISA India Chapter) is to be prepared/issued


in favor of "IISA 2000-2001 INDIA JSM" payable at State Bank of India, Center for
Engineering Studies Branch, CUSAT ( Branch Code: 10559), Cochin and should be sent
by SPEEDPOST to Dr. N. Balakrishna at the following address:
Professor N. Balakrishna
Department of Statistics
Cochin University of Science and Technology
Cochin 682022, Kerala, India
Ph: 0484 2575893, E-mail: balajicusat@yahoo.com or, nb@cusat.ac.in

The membership fee may also be paid online to the above account. The details required
for online payment are
Branch Name: Centre for Engineering Studied
Name of the account holder: IISA 2000 2001 INDIA JSM
S/b A/C No: 10851298377
IFSC Code: SBIN0010559

If the fee is paid online, please send the application form along with the details of
payment to the above address.

You might also like