| 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. | |
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MEMBERSHIP FORM | |
| Name: |
A. S. I. Membership No.: |
| Age: | Email: |
| Address: |
Residence Tel.: |
| Designation: | |
| Name of your Institute: | |
| Interest in Colo-Rectal Surgery (Number of Years): | |
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Publications & Presentations:
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| Life Membership |
Rs. 2000.00 |
| Bank Charges | Rs. 20.00 |
| Total: Rs. | Rs. 2020.00 |
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Proposed By: |
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. N. Agarwal | Dr.
Shantikumar D. Chivate Jeevan Jyot Hospital Naupada THANE 400602 Mobile 9869168730 Office:22-25406465,25409425, 25380778 Resi: 25806456 email: infodoctors@yahoo.com |
| FOR OFFICE USE Office Information Registered Editor Informed : Receipt and Constitution copy sent: Cheque/Draft Deposit: Remarks: | |
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