ISGTNC

Application Form For Membership

Date:

Name Dr:

Qualification:

MC Reg.No:

Designation:

Mobile:

Email:

Date Of Birth:

Field of Medicine Connected with Gastroenterology: :

Attachment to the Hospitals(Areas of special intrest):

Address(Residence):

I am also a Member of the Following Association (S) / Society(ies)as well A:

I am also a Member of the Following Association (S) / Society(ies)as well B:

Recommended by an existing member:

*Payment Details

Payment Date:

Payment Mode:

Bank:

Amount:

Membership Fees: Draft/Cheques in favour of ISG-TN Chapter payable at Chennai

Life Member - Rs.2500/-
PG Student(Temporary) - Rs.500/-

Add Rs.50/- for Outstation Cheques

Bank Details:

Acc Name        : INDIAN SOCIETY OF GASTROENTEROLOGY-TN CHAPTER
Bank Name     : INDIAN OVERSEAS BANK
Bank Branch   : INDIAN OVERSEAS BANK COLLEGE ROAD
Account No     : 142301000019216
Account Type  : Savings Account
IFSC CODE       : IOBA0001423
MICR CODE     : 600020076

Bank Address:

NO 23, 2ND MAIN ROAD, CIT COLONY, MYLAPORE, CHENNAI - 600004