Mensa Chennai Test Request Form

First Name

Middle Name

Last Name

Name:
DOB:
Address:

City:

State:

Mobile:

Pin:

Residence:

Telephone:
Email:

Tell us about yourself:

Education, Hobbies,
Other Interests.

How did you hear

about MENSA?

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

Affix
photo
here

X
Name :

Place :

Mensa India (Chennai)

C/o Gowri Shanker, 4/241 MGR Salai, Palavakkam, Chennai 600041

Mail: info@mensachennai.org Website: http://www.mensachennai.org

Signature of Applicant

Date :

Terms, Conditions and Disclaimer

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 him/her 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(ii) If the results have already been declared, then the same shall be rescinded;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be summarily rescinded and permanently cancelled.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 has been paid to Mensa India for the conduct of the test.