Wikimedia ChapterNo.194, 2nd C Cross, Dommaluru 2nd stage, Bangalore-560071Email: membership@wikimedia.in Website : http://wikimedia.in

Application for Individual MembershipNew/Renewal

For Office Use Only

Membership No.

Receipt No.

Receipt Date

I here by apply for fresh/renewal of membership of Wikimedia Chapter. On approval of membership, I shall

abide by the MOA, Rules and Regulations of Wikimedia Chapter.

1. Title of the Applicant: Dr. / Prof. / Mr. / Ms. / Other (specify) : ___________

(*)Surname: __________________________ (*)Given Name:_________________________

2. (*)Date of birth(DD-MM-YYYY): ____________________

3. (*)Postal Address (BLOCK LETTERS)(at which mail / other correspondence can be sent)

Address Line1:_______________________________________________

Address Line2:_______________________________________________

City/District:_________________________________________________

PIN:_____________________

State:______________________________

4. (*)Membership application type: New / Renewal

(*)If an existing member proposing to renew, enter current membership No:__________

5. (*)Payment Details

Electronic Transfer (NEFT or State bank interbranch)

of Rs 100/- to Wikimedia Chapter account with State Bank of India, Jayanagar 2nd Block,

Bangalore SB A/c.No 31682050396 (IFSC SBIN0003286). My Bank IFSC:_____________________

Transaction ID: ___________________________ Date of Transaction:_____________

OR

DD/ Cheque (Add Rs 25 towards collection charges for outstation cheques)

DD/Cheque No. ______________ dated ________________for Rs. _____ drawn in favour of

“Wikimedia Chapter” payable at par at Bangalore. (Write Name, and Membership No.(if

applicable) on the reverse of the DD/Cheque)

6. Phone: Mobile No. ________________________ Landline with std code: ______________________

7. E-mail ID:___________________________________________

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8. Gender: Male/Female

9. Vocation: Student/Academia/Industry/Government Service/Others

10. Field of Interest : Science and Engineering/Humanities

11. Highest Educational qualification: Primary/Secondary/Higher

12. Preferred language as a reader on Wikimedia projects:_______________

13. Preferred language as a contributor on Wikimedia projects:______________

14. Wikimedia Projects Username:________________________

15. Wikimedia.in Community wiki# username:_________________________

Undertaking :

I affirm that as a Wikimedia Chapter Member(WMC), I shall uphold the objectives of the WMC and

shall not engage in conduct or behaviour that is prejudicial to its interests.

I was not a member of WMC earlier / I was a member with membership No. __________________ and was

discharged without restriction on reapplication ….............. (strikeout whatever is not applicable).

I certify that the above information is true to the best of my knowledge and belief.

(*)Place :___________(*) Date: ____________ (*)Signature ___________________________

Notes:

1. Indian Citizens of age 18 and above are eligible to for membership

2. Complete this application form by filling in BLOCK LETTERS/striking off as appropriate and then

send the form with payment instruments or details to Chapter office

3. Fields prefixed with with '* ' are mandatory except for renewal applicants. If any such entry for

example surname, is not relevant, please fill it with dashes. Renewal applicants need to fill

sections 1, 4, 5, Undertaking, and any other details that have changed since their previous

membership application/renewal.

4. Membership year Apr-Mar

5. Please allow 4 weeks for processing of membership.

6. #Wikimedia.in community wiki username will be used to enable access to members wiki.

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