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I/We	(Last Name)	(First Name)	(Middle Name)

of Company is/are engaged in plastics and/or plastic related industries, desire membership of Indian Plastics Institute. If the membership is accepted, I/we agree to abide by the current rules and regulations of the Institute or as they may at any time be amended.

I/We am/are sending (please enter payment details here) dated (DD/MM/YYYY) Rs. with this application towards my/our first year's subscription and entrance fee. I/We understand that the subsription fee becomes renewable on 1st April of each year.

Date:

My Application has been proposed and seconded by the following people

Name of Proposer

Name of Seconder

Date of Birth	(DD/MM/YYYY)
Category
If Affiliated to IOM
Classification of Member
Qualifications (Academic/Professional)
Area of Specialisation
Present Occupation / Designation
In Plastic Industry since
Business Address
City
State
Country
Pincode
STD/ISD Code
Telephone 1
Telephone 2
Fax
Mobile No.
Residence Address
City
State
Country
Pincode
STD/ISD Code
Telephone 1
Telephone 2
Fax
Address for Communication	Business Residence
Email Address
Web site
Products/Services Offered
Professional Membership of the other bodies
Chapter / Sub-Chapter to be attached:
Can you devote some times for IPI activities? If yes,
Any additional information/Remarks
In case of a company
Authorised Representative 1
Designation 1
Authorised Representative 2
Designation 2

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