Isa membership

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APPLICATIONFORMEMBERSHIPOF
THEINDIANSOCIETYOFANAESTHESIOLOGISTS
(FOUNDEDIN1947)
ForyourIDfirstAlphabet:/Life/LifeAssociate
.
NAME
ADDRESS
CITY DISTRICT
STATE PIN
STDCODE
E-MAILID .
BloodGroup DateofBirth
MEDICALREGISTRATIONNo&STATE .
QUALIFICATIONS COLLEGE UNIVERSITY YEARPASSED
M.B.B.S
APPOINTMENTS
PROPOSEDBYDr. ISANo Signature
SECONDEDBYDr. ISANo Signature
ISABRANCH
..
STATE:
MoneytobesentbyDDinfavourof"IndianSocietyofAnaesthesiologists"PayableatKakinada
D.D.No .Dated ..Bank AmountRs
Alongwiththedraftpleaseenclose:
1.2PassportsizePhotos(Pleasewriteyournameincapsatthebackofthephotos)
2.CopyofMedicalRegistrationCertificateforAnaesthesiaQualification/UniversityDegree/Diploma/
NationalBoardCertificate(pleasetick)
3.ForAssociatemember-copyofMBBScertificate
DateofApplication
Forwardedby ..City/Statebranch SIGNATUREOFTHEAPPLICANT
SignatureofBr.Secretarywithseal
SUBSCRIPTION
LIFEMEMBER-Rs.5000/-
OVERSEASMEMBERSHIP
LIFEMEMBERS-US$500/-ORDINARYMEMBER-US$100/-VISITINGMEMBER-US$50/-
(FORCOMPUTER/OFFICIALUSE-PLEASEFILLINBLOCKLETTERS.)
ISANO. TYPEOFMEMBERSHIP:LifeAssociate/LIFE
RECEIPTNO&DATE AGBMDate
Dr.S.S.C.Chakrarao
Hony.Secretary-ISA(HQ),
Secretariat:67-BShantiNagar,Kakinada-533003;AndhraPradesh
MOBILE:09440176634
E-Mail:[email protected],web:www.isaweb.in
Phone: Mobile:
Photo
3.5x2.5cm
FATHER'S NAME
4. For Online Deposit : A/c.No - 30641669810, STATE BANK OF INDIA , PBB ,Kakinada. IFS Code: SBIN0004244.