Instructions for submission of the Application
form
This
form is modified for Mumbai branch. Please take a printout of the form
and fill all the information in block letters.
Pay two cheques as follows:
1.
To “ Dr. G. S. Ambardekar Anaesthesia Society “ Rs. 500 ( Five Hundred)
2.
To “Indian Society of A’logists-Mumbai Branch”. Rs. 3550 (Three thousand
five hundred fifty )
Attach one stamp size
photograph with the name written on the back and affix another photograph
on the application form.
Send the form, photos &
cheque by post to:
Attention - Dr. Manju
Gandhi, Secretary, ‘ISA-Mumbai’,
Department of Anaesthesia, B
Y L Nair Hospital, Bombay central, Mumbai, 400 008
For
queries regarding the application, contact secretary ISA-Mumbai at 2301 8136 or
2308 1490 (Ext. 332, 333, 334)
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Indian
Society of Anaesthesiologist - Mumbai Branch
& Dr G S Ambardekar Anaeshtesia Society
APPLICATION
FOR MEMBERSHIP TO THE INDIAN SOCIETY OF ANAESTHESIOLOGISTS
(FOUNDED IN 1947) (Reg. No. 8/1999)
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(Please
fill all information in block letters)
| NAME
IN FULL (Block Letters): |
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| POSTAL
ADDRESS : |
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City …………………...…
Dist............................... State ...............................
Pincode.......................
Tel. No. (R) .................................... (O)
......................................... (Please mention
STD Code also)
Mobile Phone No .............................. (E-Mail)
.................................... Blood Group ...............................
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Affix
stamp size photograph
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PROFFESSIONAL DETAILS
MEDICAL REG NO. & STATE: _____________________________________________________________
| Qualification |
College |
Univ. |
YR.Passed |
| (A)
MBBS |
. |
. |
. |
| (B) |
. |
. |
. |
| (C) |
. |
. |
. |
| Appointments
Held Current): |
______________________________________________ |
| Special
Interests : |
______________________________________________ |
| Proposed
by doctor: ___________________________________ |
I.S.A.
NO: ________________________ |
| Seconded
by doctor: ___________________________________ |
I.S.A.
NO: ________________________ |
City Branch /Direct:
_______________________ State: _______________________
Details of subscription payment:
(Cheque/DD in the name of "Indian society of Anaesthesiologists
- Mumbai Branch" payable at Mumbai)
Cheque/DD No:________________ Dated:____________ Bank Name/Branch:______________________
Rs.____________
Date________________
SIGNATURE OF APPLICANT ________________
SUBSCRIPTION:
Life members- Rs 3500 + Rs 50; Ordinary members- Rs 350 + Rs 50;
Associate member- Rs 250 + Rs 50; Visiting member Rs 300 + Rs 50;
( Enrolment fee Rs 50, For Cheque add Rs 75)
OVERSEAS MEMBERSHIP:
Life members- US $ 500; Ordinary members- US $ 100; Visiting member
US $ 50
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Office use
only: |
MEM
NO:________________ TYPE: Annual/Life:________________ LF Associate:________________
RECEIPT NO & DATE:________________
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| Date________________ |
Signature
of Hon. Secretary (national)
PROF. J RANGNATHAN
HON SECRETARY-ISA NATIONAL, P O BOX NO: 567,
B-30 (11/30) BHARATHIYAR STREET,
SUBRAMANIYA NAGAR, SALEM -636 005
TEL: 0427 2335336, FAX: 0427 2335337
MOBILE: 98427 03318, 0427 3100476
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