Bring this to the test venue with you.

Test Request Form

Write clearly in BLOCK LETTERS

Full Name:_____________________________

Date of Birth: __________________________

Correspondence Address:

City:________________State: _____________Pincode: ____________

Education: __________________________

Profession: __________________________

Telephone: (O)_______________(R) ____________(M)___________

Fax: Email:

How did you come to know about Mensa?:

I, the applicant, understand that this is only a test request form and I have read and understood the terms, conditions and disclaimer. I accept the terms, conditions and disclaimer unconditionally and unequivocally.

Name:

Place:

Signature: Date:

TERMS, CONDITIONS AND DISCLAIMER

Paste onephoto in this box. (Please do NOT

staple)

TEST FEE OF RS. 300 HAS TO BE PAID IN CASH BEFORE THE TEST. DO NOT SEND ANY MONEY WITH THE FORM.

TEST DATE, TIME AND VENUE WILL BE EMAILED TO YOU ATLEAST A WEEK BEFORE THE TEST.

- FOR OFFICE USE ONLY –TRF Received On: Receipt No: Dated: Notes:

Be environment friendly! Print on both sides of

the paper.

1. Mensa India is a Chapter of Mensa International, see www.mensa.org

2. The form being submitted is merely a request form. Mensa India is under no obligation to accept any such request and acceptance of any request shall be at the discretion of Mensa India.

3. The applicant by submission of the form undertakes that the information given by her/him in the request form is true to the best of his/her knowledge, information and belief and that the same does not contain any false or misleading information.

4. Any violation of the undertaking contained in clause 3 above or if the applicant is found to have submitted any false or misleading information or is determined by Mensa India to have in any manner used unfair means to render himself eligible for membership including in the course of appearing for the entrance test, then

a. the applicant will be disqualified from appearing for the entrance test and if has already appeared for the entrance test then:

(i) The result will be withheld, and

(ii) If the results have already been declared, then the same shall be rescinded; and it will be deemed as if the applicant had not appeared for the test;

b. If the applicant is already admitted to the membership of Mensa India, then the membership shall be summarily rescinded and permanently cancelled.

5 . Any applicant who has been found to have furnished false or misleading information in the request form or used unfair means for being admitted as a member or in the entrance test may be barred from becoming a member of Mensa in the future for a period to be decided by Mensa India. Such period may be a lifetime ban.

6. Mensa India may also cancel the membership of any applicant who has been admitted as a member, after giving notice to the person concerned.

7. In the event of an applicant not being present for the test at the designated time and place, Mensa India shall not be liable to refund or give any credit in respect of any money, either in part or in full, which might have been paid to Mensa India for the conduct of the test.

TEST DATE, VENUE AND TIME

These will be emailed to you at least one week before the test.

A PHOTOCOPY OF THIS FORM CAN ALSO BE USED. NEED NOT PRINT P2