From Date :

To

UNITED WRITERS' ASSOCIATION

32, Parameshwara Avenue,
V.R.S. Nagar,
Maduravoyil, Chennai - 600 095.

Sir,

I furnish hereunder the following particulars for seeking FELLOWSHIP OF UWA.

1. Name :

2. Address : Phone :

3.Present Position :

4. Academic Qualifications :

5. Area of Specialization :

6. Publication if any :

7. Academic Distinctions :

8. Membership of other Assns. :

9. Any relevant remarks you want to specify :

10. Enclosed Cheque / Draft for Rs.750/- for Fellowship Fee. (Cheques * /Drafts should

be drawn in favour of “United Writers’ Association, Chennai”)
Life Fellow Membership Fee : Rs.3000/-

* Outstation Cheques should include extra bank charges. Cheques are valid subject to encashment.

11. Please enclose copy of Passport size photo :

I hereby abide by the International Code of Ethics and will strive my best in upholding the objectives of UWA.

Date : Signature :