Details of payment : Cash/Demand Draft/Cheque/Online
North Zone Chapter
Urological Society of India
Membership Application Form
Category of applied for:
Full
Associates
Name (Use Block Letters) :
First Name
Middle Name
Please tick the appropriate box for preferred address for communication:
Address Residence
Address Ofiice
Residence Address
Office Address
[Upload .jpeg file only]
Address
Address
Pincode
Pincode
Tel.(Res.)
Tel.(Office)
Email
Mobile No.
Fax No.
Date of Birth
Present Appointment & Designation
Designation
Institute
Year of Joining
Acedemic Qualifications:
Degree/Diploma
Year of Passing
University
Training in Urology:
Training in Urology
Period of Training
University/College/Hospital
USI Member: Yes/No
Yes
No
Only to be filled if you are USI member
If Yes, USI No.
Select Category
--Select Category--
Full
Associates
Other
Membership Fee (Life) :INR.5,000/ +18% IGST (From 1st July 2017)= INR 5900/
Overseas (Excluding SAARC Countries) : US$ 287.5/-
Select Category
--Select--
Cheque
Draft
Online
Dated
Drawn on
(Please add Rs. 35/- for oustation cheques)
I declare that the information given above is correct and if elected, I agree to abide by the constitution of the Urological Society of India. If applying for full membership of the North Zone, I further declare that i am not a full member of any other zone of the USI and will relinquish full membership of the North Zone while applying for full membership of any other zone of the USI.
*
Note :
Only fullmembers of the parent body, USI, are eligibleto become full members of Zonal Chapters. Full members of other zones can become associate members of North Zone. A member cannot be a full member of two different zones.
Only life membership is accepted.
If the payment is madeby draft/cheque should be account payee and drawn in favour of
'North Zone Chapter-Urological Society of India'
, it payble in New Delhi.
Place
Date
[Please attach self-attested copies of the documents for qualification and training in urology.]