THE ANATOMICAL SOCIETY OF INDIA

					                                   ANATOMICAL SOCIETY OF INDIA
                                                 Regn. No. 2149 of 2004 – 05)

                                         APPLICATION FOR MEMBERSHIP
To,                                                                                           Membership
The General Secretary
The Anatomical Society of India,                                                              No…………
………………………………….

         I desire to enlist myself as an Ordinary / Life Member of The Anatomical Society of India for/from the year ………………
I agree to abide by all the Rules and Regulations of the Society as given in its Constitution and as passed in its General Body
Meetings from time to time. I am enclosing Cash / Bank Draft No. ……………………………, dated……………….., on (Name of
Bank) ………...………………………………., in favour of the Treasurer, Anatomical Society of India, payable at LUCKNOW,
for Rs. …………….., towards the admission fees and the subscription for the year.

NAME IN FULL (in Block Letters)

First name………………………………Middle Name…………..…………..….Surname…………….…………..……….

QUALIFICATIONS WITH YEARS:                (1)………………………..(2)………………………(3)………………………


PRESENT DESIGNATION / NAME OF THE DEPARTMENT / POATAL ADDRESS OF THE INSTITUTION:
………………………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………………………

COMPLETE POSTAL ADDRESS (Residential) with PIN CODE and STATE :
………………………………………………………………………………………………………………………….……………….…..
………………………………………………………………………………………………………………………………………………
Proposed by:
………………………………………………………………………………………………………………………………………………
(Signature, Name and Address of the valid member of the ASI)

Seconded by:
………………………………………………………………………………………………………………………...…………………….
(Signature, Name and Address of the valid member of the ASI)


Signature of TREASURER                    Signature of GEN. SECRETARY
of the ASI with date of Receipt           of the ASI                                          Signature of the APPLICANT

                                                   ( For EDITOR’s office record)                     Membership
                                          Please send the JOURNAL at the following address:
                                                                                                     No…………

NAME of the MEMBER with COMPLETE POSTAL ADDRESS, PIN CODE and STATE :
………………………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………………………

                                                                                    Signature of TREASURER of the ASI


                                                  ( For TREASURER’s office record)                   Membership

                                                                                                     No………….

NAME of the MEMBER with COMPLETE POSTAL ADDRESS, PIN CODE and STATE :
………………………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………………………
Details of the CASH / BANK DRAFT in favour of the TREASURER, ANATOIMICAL SOCIETY OF INDIA:
Bank Draft No. ………………………….. Dated……………………,
Name of the Bank………………………………for Rs…………..….,
Payable at LUCKNOW                                                    Signature of the TREASURER of the ASI
                                              BIODATA PROFORMA
                        (Kindly furnish the following information for the Membership Directory)
Date of Birth:
Academic Qualifications:
Sl.    Qualifications        Year             College / Institution / Academic Body                 University
No.
      MBBS
      MSc
      MS / MD
      DNB
      PhD
      DSc



Year / Date of joining Anatomy Department:………………… As (Designation)……………………………….

Year / Date of joining the ASI as: Ordinary Member……………………. Membership No. ……………………….

                                    Life Member………………………….
                  OFFICE                             PRESENT                                       PERMANENT
                                                     RESIDENCE                                     RESIDENCE
Address:




Phone: ……….. …………………………………………………………………………………………………………………
Fax:   ……….. ………………………Mobile No… …………………………E-mail………………………………………….

National / International Awards:

Field of Research:

Participation in International Conferences etc.

Any other Special Information:


>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>




                                      (Membership from 1st January to 31st December each year)

INDIA: Enrollment Fee -Rs. 100=00, ORDINARY MEMBER: Annual Subscription - Rs. 500=00, COUPLE MEMBERS:
Rs. 800=00 + two enrollment fees, LIFE MEMBER (all the categories) – Rs. 5000=00 (Life membership) + Rs. 50=00 (Cost of
the Constitution Copy) + Rs. 500=00 (Ordinary Membership of current year) + Rs. 100=00 (Enrollment Fees for the current year)
TOTAL Rs. 5650/-. FOREIGN COUNTRY: Enrollment Fee: 10 USD, Ordinary Membership-70 US Dollars, Life Member–700
US Dollars + Cost of Constitution 10 USD + 70 UDS (Ordinary Membership) + 10 USD (Enrollment fees) of the current year (total
USD 790).

BANK COLLECTION: add Rs. 60=00 or USD 10=00.



Please post this form along with the Bank Draft at the following address:-
Dr. A. K. Srivastava, Treasurer of the ASI, Professor, Department of Anatomy,
C. S. M. Medical University (Upgraded K. G’s. Medical College),
LUCKNOW – 226 003 UP INDIA.

				
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