MEMBERSHIP APPLICATION FORM

MEMBERSHIP APPLICATION FORM


Founders

President: Dr. B. .N. Chakravarty, D. Sc., MD, FRCOG, FRCS

Secretary General: Mr. Pramathes Das Mahapatra, MD, FRCOG, FRCS

Assistant Secretary: Dr. Abhijit Ghosh, DNB

Treasurer: Dr. Nirmala Pipara, MD

Members: Dr. Pradip Kumar Mitra, MD Dr. Mandira Mukherjee, DGO Dr. Sangeeta Agarwal, DGO

Name:
 
Surname   Title   First name:
   
 
Full Mailing address:
 
 
PIN Code : 
 
 
Telephone No:
 
STD code   Personal   Office
   
 
Mobile No:   FAX:
   
 
e-mail:
 
 
Affiliated Hospital or Company:    
     
(1)  
     
(2)  
 
Qualification:
 
Degree/Diploma  University/College Year
 
1.      
 
2.      
 
3.      
 
4.      
 
5.      
 
6.      
 
 
 
Medical Registrations:
 
Registration No. Registering Body                  Year
 
1.      
 
2.      
 
3.      
 
 
Membership  of  other Organisations :
 
Organisation Type of Membership                  Since
 
1.      
 
2.      
 
3.      
 
4.      
 
5.      
 

Membership categories and fees

 
LIFE MEMBER: Rupees Five Thousand only ( 5,000.00 )
 
ASSOCIATE MEMBER (Other Than Medical Doctors ): Rupees Two thousand and five hundred only (2,500.00)
 
INSTITUTIONAL MEMBER: Negotiable
 
( e.g. Pharmaceutical members )
 
Mode of payment (put tick mark):
 
Cash       Cheque     Demand Draft  
 
Please draw cheque (only on any bank at Kolkata) OR demand draft  (payable at Kolkata) in favour of "ENDOMETRIOSIS SOCIETY, INDIA"
 
Amount Paid:
 
Rs.   (In words)     only
 
Cheque /Draft Number:
 
 
Date of Issue:
 
 
 
 
Name of Bank and branch:
 
 

Donation
 
Mode of payment (put tick mark):
 
Cash       Cheque     Demand Draft  
 
Please draw cheque (only on any bank at Kolkata) OR demand draft  (payable at Kolkata) in favour of "ENDOMETRIOSIS SOCIETY,INDIA "
 
Amount Paid:
 
Rs.   (In words)     only
 
Cheque /Draft Number:
 
 
Date of Issue:
 
 
Name of Bank and branch:
 
 
Signature
 
 
Date
 
 
 
                       

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