(Affix Passport Sized Photo) MEMBERSHIP APPLICATION FORM Please review the Membership Eligibility Criteria specified on Page 3 carefully before you fill in this form. All fields are compulsory. Incomplete forms or forms submitted without the required documentation may not be processed. GENERAL INFORMATION Full Name Father’s full name Current Occupation Please attach a self-attested copy of your PAN Card. Please note that this is mandatory. Identity Proof (self-attested copy of any one of the following to be attached): Passport Voter ID Driving License Date of Birth D D M M Y Y Y Y Current Address (Please attach a self-attested copy of your latest address proof): Mobile No. Email MEMBERSHIP ELIGIBILITY Membership Category: Senior Men’s Senior Women’s (Tick all Applicable) Level of Cricket Played: Senior Men’s International Senior Men’s First Class (Tick all Applicable) Senior Women’s International Senior Women’s First Class Year of Retirement: Y Y Y Y Number of International Matches Played (if any): Number of First Class Matches Played: Senior Team(s) Represented at First Class and/or International Level and Time Period(s) (Please list all): Please provide the names and contact details for two references who played with you in the team(s) mentioned above. Reference 1: Name: Mobile No. Email Reference 2: Name: Mobile No. Email Page 1 of 3 PREFERRED ICA CHAPTER (Please tick only one) Members have the option to choose membership of the ICA Chapter of the BCCI Member Association for which they have played a First Class Match or in whose jurisdiction the member is currently resident. Please note that there will be no Chapters for Railways Sports Promotion Board (RSPB), Armed Forces/Services or All India Universities (AIU) and any applicants who have represented such BCCI Member Association(s) may select the ICA Chapter for another BCCI Member Association they may have also represented or the jurisdiction of the BCCI Member Association they currently reside in as their preferred ICA Chapter. Subject to the aforesaid criteria, membership to an ICA Chapter may be changed by a member no more than once each calendar year. Andhra Cricket Association Maharashtra Cricket Association Arunachal Cricket Association Manipur Cricket Association Assam Cricket Association Meghalaya Cricket Association Baroda Cricket Association Cricket Association of Mizoram Bihar Cricket Association Mumbai Cricket Association Chattisgarh State Cricket Sangh Nagaland Cricket Association Delhi District Cricket Association Odisha Cricket Association Goa Cricket Association Punjab Cricket Association Gujarat Cricket Association Rajasthan Cricket Association Haryana Cricket Association Saurashtra Cricket Association Himachal Pradesh Cricket Association Sikkim Cricket Association Hyderabad Cricket Association Tamil Nadu Cricket Association Jammu and Kashmir Cricket Association Tripura Cricket Association Jharkand State Cricket Association Uttar Pradesh Cricket Association Karnataka State Cricket Association Cricket Association of Uttarakhand Kerala Cricket Association Vidharba Cricket Association Madhya Pradesh Cricket Association Cricket Association of West Bengal Cricket Association of Pondicherry BASIS OF CHAPTER PREFERENCE (Please tick only one) Played for relevant BCCI Member Association Current resident in jurisdiction of relevant BCCI Member Association Page 2 of 3 SUBMISSION OF APPLICATION The duly filled and signed application form along with the attachments requested should be emailed to [email protected] prior to the last date specified on the ICA website. Applications received after the last date specified may not be processed. DECLARATION 1. I hereby represent that the email address and mobile number specified by me in the Form are used by me and under my control and agree that the ICA may contact me using the details provided. I further agree that in case I change my email address and mobile number at any time during the course of my membership with the ICA, I shall notify the ICA by email no later than 30 days from the date on which email/mobile number has changed and specify the updated contact details on which I may be contacted. 2. I hereby consent to the ICA collecting and storing my identification proof and address proof documentation and conducting necessary background checks, which may include but not be limited to, contacting the relevant cricket governing body (such as the Board of Control for Cricket in India (BCCI) or its Member Associations) or the references provided by me, for the purpose of verifying the information provided in the Form. 3. I acknowledge that my submission of this Form does not guarantee that I will be provided Membership and that the grant of Membership will be subject to me completing all formalities as may be specified by the ICA. 4. I hereby agree and understand that while there is no membership fee being collected from me by the ICA at the time of submission of this Form, the continuation and renewal of my ICA membership shall be subject to me making payment of the requisite membership fee (including any arrears of membership fee), upon demand by the ICA in the future. 5. I hereby represent, warrant and confirm that the information provided by me in this Form is truthful and accurate to the best of my knowledge and that I have not provided any false or inaccurate information in this Form. I acknowledge and agree that in the event that I have been found to have made any false representations or acted fraudulently with respect to any information provided in this form, I may be subject to legal proceedings from the ICA and the ICA may, at its discretion, temporarily or permanently debar me from membership to the ICA. Date Place Signature Page 3 of 3 MEMBERSHIP ELIGIBILITY CRITERIA 1. Cricketers who have retired from all forms of the game and meet the following criteria shall be entitled to apply for membership of the ICA: (i) Male and female ex-cricketers, who have played at least one International Cricket Match in any format of the game at the senior level; (ii) Male ex-cricketers, who have played at least Ten First Class Matches in any format of the game at the senior level (see notes in para 2 below); (iii) Female ex-cricketers, who have played at least Five First Class Matches in any format of the game at the senior level (see notes in para 2 below); and (iv) Differently-abled ex-cricketers, who have played either International Cricket or first class cricket, where such cricket is recognised as such by the ICC or the BCCI and is organised by the BCCI or a body recognised by the ICC or the BCCI, in any format of the game at the senior level. It is to be noted that, currently, no such cricket is recognised by the ICC or the BCCI or organised by the BCCI or a body recognised by the ICC or the BCCI and the ICA will continue to monitor the same for the purposes of the membership process. 2. In relation to the aforesaid membership criteria a “First Class Match” shall mean and include, in the context of male and female cricketers, a senior match organised by the BCCI (and, in the case of female cricketers, a senior match organised by the Women’s Cricket Association of India prior to November 14, 2006, i.e., before the BCCI took over the governance of women’s cricket) or involving a team selected by the BCCI (and, in the case of female cricketers, a senior match organised by the Women’s Cricket Association of India prior to November 14, 2006, i.e., before the BCCI took over the governance of women’s cricket) and that qualifies as ‘First-Class’ under the ICC Classification of Official Cricket (as applicable from time to time); provided that: a) Every 3 senior One Day limited overs matches forming a part of any BCCI organised inter-state or inter-zonal tournament(s); and b) Every 5 senior Twenty20 matches forming a part of any BCCI organised inter-state or inter-zonal tournament(s); shall also be classified for the purposes hereof as one ‘First Class Match’, it being clarified that any fractions shall be rounded off to the lower whole number..