Chandigarh Ophthalmological Society

Chandigarh Ophthalmological Society Annual Conference on 21st August, 2005

CHANDIGARH OPHTHALMOLOGICAL SOCIETY (REGD.)
LIFE MEMBERSHIP APPLICATION FORM

NAME______________________________________________________________________________

(In Block Letters, Begning with Surname)

DESIGNATION/EXPERIENCE___________________________________________________________

DATE OF BIRTH AGE SEX MARTIAL STATUS_____________________________________________

NAME & DATE OF BIRTH OF SPOUSE__________________________________________________

MARRIGE ANNEVERSARY____________________________________________________________

DETAILS ABOUT SPOUSE AND CHILDREN :

CLINICAL/OFFICE ADDRESS_________________________________
PHONE_____________

RESIDENTIAL ADDRESS___________________________________ PHONE_____________

QUALIFICATION	UNIVERSTY	YEAR
_____________________ _____________________ _____________________	________________________________ ________________________________ ________________________________	_____________ _____________ _____________

FIELD OF SPECIAL INTEREST__________________________________________________________

REGISTRATION NO. & STATE___________________________________________________________
(In which registered)

PROPOSED BY (Name & Membership)
____________________________________________________________________________________

____________________________________________________________________________________

Hobbies_____________________________________________________________________________

Signature____________________________________________________________________________

DECLARATION

I wish to be a member of chandigarh Ophthalmological Society

I declare that the above details are correct.

I shall abide by society rules in force and subsequent amendment

I am enclosing Rs. 1000/- by cheque/Draft

__________________________________

Date __________________________________________Signature _______________________________

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