PEFAA – Colombo Chapter

C/O Ceylex Engineering (Pvt.) Ltd, 17th floor, Parkland, 33, Park street, Colombo 02, Sri Lanka

FOR OFFICE USE ONLY

Membership No:

APPLICATION FORM FOR MEMBERSHIP

PERSONAL DETAILS
1.Title (Prof/Dr/Mr/Mrs/Miss/Ms)* 2.Family Name* 3.Date of Birth (dd/mm/yyyy)*

4.Other Names 5.Registartion No (eg: E/XX/XXX)*

6. Member of PEFAA Mother Chapter*

Yes No

7. Designation* 8. Organization*

9. Official Address Telephone Number

Mobile Number

Email*

10. Residential Address* Telephone Number

Mobile Number*

Email*

11. Preferred Mailing Address* 12. Would you allow your personal details to be published on the PEFAA
Home Office official website?
Yes No
*Mandatory fields

EDUCATIONAL QUALIFICATIONS
13. Type of Association with the Faculty
Undergraduate Postgraduate Academic Staff Non-Academic Staff
14. Degrees/Qualifications Obtained from the Faculty* 15. Year of Award

16. Other Academic & Professional Qualifications

17. Specialization*
Civil Engineering Electrical & Electronic Engineering Mechanical Engineering Other
Production Engineering Chemical Engineering Computer Engineering
 PEFAA – Colombo Chapter
C/O Ceylex Engineering (Pvt.) Ltd, 17th floor, Parkland, 33, Park street, Colombo 02, Sri Lanka

SUBSCRIPTION
18. Amount Paid (See Notes)* Mode of Payment*
Cash (Bank Deposit) Cheque Online

Bank & Account Details: Reference Number of Transaction*

Bank of Ceylon
Independent Square Branch
No: 30/ A, Independent Avenue,
Independent Square,
Colombo 07
Account Name: PEFAA Colombo Chapter
Current Account No - 82774659
Savings Account No - 82774449
I certify that the above particulars are true and correct.
Date (dd/mm/yyyy)* Signature*

NOTES

1. Membership Fee

 Annual Membership Fee – Rs. 1,000 /= (Annual Payment)

 Life Membership Fee – Rs. 10,000 /= (One Time Payment)

2. Mode of Payment

 Bank Deposits – Scan copy of the deposit slip to be attached with the application form
 Cheque – Cheque should be written in favor of “PEFAA Colombo Chapter” (Cheque should
be delivered OR sent by register post to the address in the letter head OR the scanned
copy of Cheque deposit slip should be attached with the application form.)
 Online Bank Transaction- Online receipt to be attached along with the filled application form

Membership is free for members above 65 years of age

3. Email: pefaa.cmb@gmail.com