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  • The Association of Breast Surgeons of India: Membership Form

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    digantpathak
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    This document is a membership form for the Association of Breast Surgeons of India (ABSI). It requests basic information like name, date of birth, degree, contact details, education and medical council registration from applicants. It also asks for details of current institution, specialization and membership of other organizations. The form lists different categories of membership - life member, associate member, overseas member and affiliate member - and their respective fees. It concludes by providing contact details of the secretary of ABSI to submit the completed form along with a demand draft.

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    ABSI Membership Form

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    This document is a membership form for the Association of Breast Surgeons of India (ABSI). It requests basic information like name, date of birth, degree, contact details, education and medical council registration from applicants. It also asks for details of current institution, specialization and membership of other organizations. The form lists different categories of membership - life member, associate member, overseas member and affiliate member - and their respective fees. It concludes by providing contact details of the secretary of ABSI to submit the completed form along with a demand draft.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd
    Flag for inappropriate content
    46 views2 pages

    The Association of Breast Surgeons of India: Membership Form

    Uploaded by

    digantpathak
    This document is a membership form for the Association of Breast Surgeons of India (ABSI). It requests basic information like name, date of birth, degree, contact details, education and medical council registration from applicants. It also asks for details of current institution, specialization and membership of other organizations. The form lists different categories of membership - life member, associate member, overseas member and affiliate member - and their respective fees. It concludes by providing contact details of the secretary of ABSI to submit the completed form along with a demand draft.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd
    Flag for inappropriate content
    of 2

    The Association of

    Breast Surgeons of India


    ABSI
    www.absi.in

    Photo required
    for preparing
    Membership card

    MEMBERSHIP FORM
    Basic Information
    Name

    : ..

    Surname

    : ..

    Date of Birth

    : ..

    Degree

    : ..

    E-Mail

    : ..

    Professional Information

    Residential Address

    Institution

    : ....... ..........

    Department

    : ....... ..........

    Address

    : ....... ..........
    ....... ..........

    City

    : ....... ..........

    State

    : ....... ..........

    Pincode

    : ....... ..........

    Phone

    : ....... ..........

    Fax

    : ....... ..........

    Education

    : ....... ..........

    MBBS
    College

    : .

    University

    : .

    Year of Passing : .
    Post Graduation
    College

    : .

    University

    : .

    Year of Passing :
    Super Speciality
    College

    University

    Year of Passing :

    Medical Council Registration


    Registration Number .......State ....................
    Whether an active member of ASI :

    Yes / No

    ASI Registration Number ..........State .............


    Whether a member of any other International Organisations IASO / OTHERS (Please Mention)
    CATEGORY OF MEMBERSHIP
    Life member: General Surgeons, Surgical Oncologists & Plastic Surgeons who are Life members of ASI
    Membership fee: Rs. 2000/Associate Member: Trainees in General Surgery, Surgical Oncology & Plastic Surgery
    Membership fee: Rs. 1500/Overseas Member: General Surgeons, Surgical Oncologists & Plastic Surgeons living overseas
    Membership fee: $ 300/Affiliate Member: Gynecologists, General Practitioners, Radiologists, Pathologists, Medical
    Oncologists, Radiation Oncologists, Breast Care Nurses, Palliative care Physicians & Breast cancer
    advocacy groups
    Membership fee: None (complimentary until March 2012)
    Demand Draft Details
    DD in favour of Association of Breast Surgeons of India (Payable at Hyderabad)
    Demand Draft No :
    Bank :

    Date :
    Place :

    Signature

    Proposed by:
    ASI Life Membership No:
    Signature
    Seconded by:
    ASI Life Membership No:
    Signature
    Contact Details

    Dr. P. Raghu Ram


    MS, FRCS (Eng), FRCS (Edin), FRCS (Glasg), FRCS (Irel)
    Hon. Secretary, ABSI
    KIMS-USHALAKSHMI Centre for Breast Diseases
    Krishna Institute of Medical Sciences Ltd.
    1-8-31/1, Minister Road, Secunderabad - 500 003.
    Andhra Pradesh, India.
    Tel: 040 - 4488 5190 / 4488 5191
    e-mail: p.raghuram@hotmail.com
    www.absi.in
    For Office Use
    Received Date : . Receipt sent on : .............
    Membership No :

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