1. ALUMNI ASSOCIATION
Faculty of Applied Sciences, Rajarata University of Sri Lanka
MeMbership ApplicAtion
General Information
Full Name : _________________________________________________________________________________
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Name with Initials : (Mr./Mrs./Miss.) _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
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Permanent Address : _________________________________________________________________________________
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Residential Address : _________________________________________________________________________________
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Telephone : ________________________________ Mobile : __________________________________
Email : _________________________________________________________________________________
Date of Birth : ________________________________
Professional Information
Designation : _________________________________________________________________________________
Office Address : _________________________________________________________________________________
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Office Telephone : _____________________________ Office Mobile : _____________________________
Office Email : _________________________________________________________________________________
Graduate Information
Batch / Year : ___________________________ Registration No : ____________________________
Membership Information
Life Membership (One-time Payment – Rs. 5000/-)
Ordinary Membership (Annual Payment – Rs. 500/-)
(Account Details: National Saving Bank – Wallampitiya - Account No: 1-0706-77-0068-7)
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Date Signature
Membership No Payment Received Date Authorized Signature
For Official Use Only