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