Life-Membership-Registration

LIFE MEMBERSHIP APPLICATION FORM FOR MP STATE OPHTHALMIC SOCIETY

PLEASE FILL ALL SECTIONS IN BLOCK LETTERS ONLY

Title

Name *

Permanent Address *

Present Address

City *

State *

Pin *

Office Tel. No.

Mobile No. *

E-Mail *

Photograph (Image Format Only)

Date of Birth *

Nationality

Gender *

Qualification Details

MBBS *

DO/DOMS

MS/(Ophth)

MCI Registration No.

Name of Medical Council

Amount:

Rs. 7,500/- + GST (Seven Thousand Five Hundred Only + GST)

Bank Details

Current Account No. 63005037709

Name: M.P. State Ophthalmic Society

Bank Name: SBI (State Bank of India)

Branch: Shop No. 1, G-2, S.V. Business Park,
77, Swami Vivekanand Colony, Khandwa Main Road,
Indore, District Indore, Madhya Pradesh - 452018

IFSC Code: SBIN0007385

Title

Name

Permanent Address

Present Address

City

Dropdown

Office Tel. No.

University Qualifying Name

E-Mail

Nationality

Gender

MBBS - Name of University

MBBS - Qualifying Year

DO / DOMS - Name of University

DO / DOMS - Qualifying Year

MS / Ophth - Name of University

MS / Ophth - Qualifying Year

MCI Registration No.

Name of Medical Council