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Application form for life Membership [Download in PDF]


Name .......................Age................. Sex ......................
Date of Birth .........................................................
Designation.................................................................................................................
Qualification ...........................................................................................................................................
Permanent Address ..............................................................................................................................
(For Communication)............................................................................................................................
...................................................................................................................................................................
Email ....................................
Mobile ..................................
Academic Details:
M.B.B.S.,
Year of Completion :..............................................................................................................................
College ..............................................................................
Post Graduation
Year of Completion :......................................................................................................
College ...............................................................................
Signature:.................................
 

DETAILS
1. Life membership fee Rs. 4000/- (inclusive of admission fee Rs. 50/-)
2. Payment to be made only by D.D/Cheque in favour of

"The Indian Society of Otology-chennai - 10
 

Address for Communication

The Secretary
Indian Society of Otology
New No.274, Old No. 827, Poonamallee High Road
Chennai - 600 010.
E-mail : 1. indiansocietyofotology@gmail.com,
Website: www.indiansocietyofotology.com

 

 

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Indian Society of Otology,
New.No.274, Old.No.827, Poonamallee High Road, Chennai - 600 010.
Phone: 044-26651145 Fax: 044-2641 2727
E-Mail: indiansocietyofotology@gmail.com