Consumer Protection Council, Rourkela
(Registered under Societies Registration Act)
B/90, Sector-7, Rourkela-769003.  Orissa.  India

Membership No. M/LM - _______________ (to be filled by the Council)




Affix passport size photo here


Name (in block letters)
 Age & Date of birth
 Occupation & Office Address
Address for Communication
Phone No.
E-mail id
Category of membership Applied for:                    Member/Life Member (tick mark as applicable)
    Amount sent:                             Details of Cheque/DD:

    (a) Are you a member of any other consumer organisation:          YES/NO (tick mark as applicable)

    (b) If  yes, state the Name of the organisation & its address

    Any other information which you would like to state
    The information furnished above are true to the best of my knowledge and belief.
          Date:                                                                                                     Signature of the applicant

Membership No. M/LM ________________
         Admitted to the Council as Member/Life Member/Application Rejected, as per Executive Committee Meeting held on     _________________.
         Date:                                                                                                                                                        SECRETARY