State Central Library, Membership Form
Content
SIAIE CENTRAL LIBMRY, KERALA
APPLICATION FOR E CLASS MEMBERSHIP [A.spcr G O. (R.t.) No. 931/2009/HJdn. drted 30-6-20091 MemberNo. l. 2. 3. Name in full (in block letters) Name Farher'sllt{other's If manied pleasestate husband's/wife'sname
Admitted on:
4.
Present Addresswith Pin Code (in full) (indicate Village, Taluk, Dishict State also)
5.
Address with Pin Code Permanent l (in tull) (indicetc Village, Taluk, District, Sate also)
6. Designation and Offtce Address (in tull) with PIN Code Office Identitv Card No. No. Telephone 9. E-mail Address 10. ArmualIncome 11. PAN (If lncomeTax Payee)
DECLARANON I desire to becomea memberin the Library. If aamitte4 I undertaketo abide by the rules of the iibrary in force, from time to time and the State Librarian's.decision regarding them. I shall bc personallyresponsiblefor any loss sustainedby the Library due to ily mbnbership and shall make good any such loss. I hcrcby nominate my father/ Shri/Srnt mother/son/daughter/husband/wife, to receive my
the nominec. I am remitting Rs. 1500bctng -y membershipddposit. refundabledepositin the event of my predeceasing of any previous membershipin the State Central Library' I do hereby declare that I am not in possession Thiruvananthapurarn
Date:
Signature.
(frT. 42t n7 0a00915.000/DTP.
a /-
Decleretion of Person Recommendingthe Applicrnt Shri/Smt. in the Library. I am a GazettedOfFrcerin the Service of Central Governmentand I shall be pcrsonally responsiblefor any loss sustained by the Library due to his/hermembership.
Sigrrature: Nam€: Designation and Offrcial address: (Office seal)
Permanent Postal (House): Address .............-.... -.. (Indicate Village, Taluk, Distict also)
N.^8.-1. Applic,btionsmust be accompanied by attestedcopy of applicants identity (Office Identity Cad). 2. Two stampsize photosshouldbe enclosed: One pastedaboveand the other one clipped loose. 3. The period of validity of E Classmembership is one year only. 4. MembershipDeposit is Rs.l500 (Refundable). 5. The loan at any one tinre: 3 books ani 2 periodicals. 6. In caseof loss of Identity Card a duplicateIdentity Card will be issuedon paymentof a fine of Rs. 50 only. An amount of Rs. 5 rvill be chargedas fine for issuing duplicate borrower's ticket. ' For office use only Recommended by: Admitted on:
MembershipNo.:
l,ibrarian-in-clarge of shift I/lI Book Room. Lending time nnd Admission time Morning: 8 a.m. to 2 p.m. Afternoon: 3 p.m. to 8 p.m. Sunday: 8 a.m. to 2 p.m.
State Librarian:
APPLICATION FOR E CLASS MEMBERSHIP [A.spcr G O. (R.t.) No. 931/2009/HJdn. drted 30-6-20091 MemberNo. l. 2. 3. Name in full (in block letters) Name Farher'sllt{other's If manied pleasestate husband's/wife'sname
Admitted on:
4.
Present Addresswith Pin Code (in full) (indicate Village, Taluk, Dishict State also)
5.
Address with Pin Code Permanent l (in tull) (indicetc Village, Taluk, District, Sate also)
6. Designation and Offtce Address (in tull) with PIN Code Office Identitv Card No. No. Telephone 9. E-mail Address 10. ArmualIncome 11. PAN (If lncomeTax Payee)
DECLARANON I desire to becomea memberin the Library. If aamitte4 I undertaketo abide by the rules of the iibrary in force, from time to time and the State Librarian's.decision regarding them. I shall bc personallyresponsiblefor any loss sustainedby the Library due to ily mbnbership and shall make good any such loss. I hcrcby nominate my father/ Shri/Srnt mother/son/daughter/husband/wife, to receive my
the nominec. I am remitting Rs. 1500bctng -y membershipddposit. refundabledepositin the event of my predeceasing of any previous membershipin the State Central Library' I do hereby declare that I am not in possession Thiruvananthapurarn
Date:
Signature.
(frT. 42t n7 0a00915.000/DTP.
a /-
Decleretion of Person Recommendingthe Applicrnt Shri/Smt. in the Library. I am a GazettedOfFrcerin the Service of Central Governmentand I shall be pcrsonally responsiblefor any loss sustained by the Library due to his/hermembership.
Sigrrature: Nam€: Designation and Offrcial address: (Office seal)
Permanent Postal (House): Address .............-.... -.. (Indicate Village, Taluk, Distict also)
N.^8.-1. Applic,btionsmust be accompanied by attestedcopy of applicants identity (Office Identity Cad). 2. Two stampsize photosshouldbe enclosed: One pastedaboveand the other one clipped loose. 3. The period of validity of E Classmembership is one year only. 4. MembershipDeposit is Rs.l500 (Refundable). 5. The loan at any one tinre: 3 books ani 2 periodicals. 6. In caseof loss of Identity Card a duplicateIdentity Card will be issuedon paymentof a fine of Rs. 50 only. An amount of Rs. 5 rvill be chargedas fine for issuing duplicate borrower's ticket. ' For office use only Recommended by: Admitted on:
MembershipNo.:
l,ibrarian-in-clarge of shift I/lI Book Room. Lending time nnd Admission time Morning: 8 a.m. to 2 p.m. Afternoon: 3 p.m. to 8 p.m. Sunday: 8 a.m. to 2 p.m.
State Librarian:
