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Transfusion Bulletin

Application for Membership

Author(s): Editor

Vol. 12, No. 2 (2004-08 - 2004-08)

APPLICATION OF MEMBERSHIP FOR ISBTI

(Please Fill-up in Block Letters)

Name of the Applicant :___________________________________________________

Father’s/Husband’s Name :________________________________________________

Date of Birth :__________________

Qualification :__________________________________________________________

Field of Activity (Please ¸ Tick the Following) :

Medical / Paramedical / Administrative / Motivation / Research / Commercial / Other

Office Address (Please Follow the Following Format) :

1. Name of the Institute :_________________________________________________

2. Designation :________________________________________________________

3. Road :_____________________________________________________________

4. Telephone Number with S.T.D. Code : State :______________________________

Residential Full Address :________________________________________________

House No. :___________________________________________________________

Street / Road / Lane :____________________________________________________

Post Office :___________________________________________________________

District :______________________________________________________________

Pin :_______________

Telephone Number with S.T.D. Code :______________________________________

Brief Outline of activities :________________________________________________

______________________________________________________________________

Type pf Membership Desired (Please ¸ Tick the Following) :

Life Member (Rs. One Thousand only)

Institutional (Rs. Five Thousand only for Voluntary Organisations)___

Institutional (Rs. Fifty Thousand only for Commercial Organisations)___

Please Pay in favour of “Indian Society of Blood Transfusion and immunohaematology” by A/c. payee

cheque (+ Rs. 50/- For Bank Charge) or by draft Payable at KOTA

Signature of Applicant :_________________________________________________

Recommended by Two Following ISBTI Members -__________________________

____________________________________________________________________

Name Signature Rubber Stamp

1.__________________________ ___________________________

2.__________________________ ___________________________

FOR OFFICE USE ONLY :

1. Sl. No. in the Register : _____________________________

2. Receipt No. _____________________________________

Mailing Address for Application form :

Dr. V. P. Gupta, President - ISBTI1-A-12 (SFS), Talawandi, Kota - 5 (Rajasthan)

Phone : 0744-2422400, 2427106, 2325205, * E-mail : [email protected]

_______________________________________________________________________________

Please circulate to other Transfusion workers to increase the membership. Life membership is more

beneficial, as you get access to office bearer posts.

Note : While following this form leave one space (square) between two words.

- Editor

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