8/22/2019 State Central Library, Membership Form

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SIAIE CENTRAL LIBMRY, KERALAAPPLICATION FOR E CLASS MEMBERSHIP

[A.spcr G O. (R.t.)No. 931/2009/HJdn. drted 30-6-20091

MemberNo.l. Name in full (in block letters)2. Farher'sllt{other'sName3. If manied pleasestate husband's/wife'sname

4. PresentAddresswith Pin Code(in full)(indicate Village, Taluk, Dishict Statealso)

5. PermanentAddress with Pin Code(in tull) (indicetcVillage, lTaluk, District, Sate also)

Admitted on:

6. Designation and Offtce Address(in tull) with PIN CodeOffice Identitv Card No.TelephoneNo.E-mail Address

10. Armual ncome11. PAN (If lncomeTax Payee)

DECLARANONI desire o becomea member n the Library. If aamitte4 I undertake o abideby the rules of the iibrary in force,

from time to time and the State Librarian's.decisionregarding hem. I shall bc personally esponsible or any losssustainedby the Library due to ily mbnbership and shall make good any such oss. I hcrcby nominatemy father/mother/son/daughter/husband/wife, hri/Srnt to receive myrefundabledeposit n the eventof my predeceasinghe nominec. I am remittingRs. 1500 bctng-y membershipddposit.I do hereby declare hat I am not in possession f any previousmembership n the State Central Library'Thiruvananthapurarn

Date:

9.

(frT. 42t 7 0a00915.000/DTP.

Signature.

8/22/2019 State Central Library, Membership Form

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a/-Decleretion of Person Recommending he Applicrnt

Shri/Smt.in the Library. I am a GazettedOfFrcern the Serviceof CentralGovernmentand I shall be pcrsonallyresponsible orany losssustained y the Library due o his/hermembership.

Sigrrature:Nam:Designation and Offrcial address:

(Office seal)

PermanentostalAddressHouse):............-......(IndicateVillage, Taluk, Distict also)

N.^8.-1. Applic,btionsmustbe accompanied y attestedcopy of applicants dentity (Office Identity Cad).2. Two stampsizephotosshouldbe enclosed: Onepastedaboveand the other one clipped oose.3. The periodof validity of E Classmemberships oneyear only.4. MembershipDeposit s Rs.l500 (Refundable).5. The loan at any one tinre: 3 booksani 2 periodicals.6. In caseof loss of IdentityCard a duplicate dentity Cardwill be issuedon paymentof a fine of Rs. 50 only.An amount of Rs. 5 rvill be chargedas fine for issuingduplicateborrower's ticket.

' For office use onlyRecommended y: Admitted on:

MembershipNo.:

l,ibrarian-in-clarge of shift I/lIBook Room.Lending time nnd Admission ime

Morning: 8 a.m. to 2 p.m.Afternoon: 3 p.m. to 8 p.m.Sunday: 8 a.m. o 2 p.m.

State Librarian: