| To become a life member of the asscociation, Print
(Ctrl+P) this page, fill up the membership form & send it to
the below mentioned address along with the bank draft. You have to
be a member of ASSOCIATION OF SURGEONS OF INDIA (A.S.I) to become a
life member of this association. |
|
MEMBERSHIP FORM |
Name:
|
A. S. I.
Membership No.: |
| Age: |
Email: |
| Address: |
Residence Tel.:
Office Tel.: |
| Designation: |
| Name of your Institute: |
| Interest in Colo-Rectal Surgery (Number of
Years): |
|
Publications & Presentations:
|
Life Membership
|
Rs.
2000.00 |
| Bank Charges |
Rs.
20.00 |
| Total: Rs. |
Rs.
2020.00 |
|
Proposed By:
Name:
Sign |
Seconded By:
Name:
Sign |
| Your Signature: |
Demand Draft payable to :-
The Association of Colon And
Rectal Surgeons of India. Payable at Mumbai.
This form and the
bank-draft should be sent to: |
| Dr. J. W. Ebenesh Bensam |
Dr.
Shekhar Suradkar
402, New Davashish,Marathon Square,E. E. Highway,Thane(W) 400 604
Mobile 9820045614
Office:022-25822683
Fax: 022 25811054
email: shekharsuradkar@yahoo.co.in |
FOR OFFICE USE
Office Information
Registered
Editor
Informed :
Receipt and Constitution copy sent:
Cheque/Draft
Deposit:
Remarks: |
|