APPLICATION FORM FOR MEMBERSHIP OF INDIAN SOCIETY OF HAEMATOLOGY TRANSFUSION MEDICINE Secretariat Address Dr H P PATI Hon General Secretary ISHTM Professor of Hematology Dept Hematology A I by ill20582

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									           APPLICATION FORM FOR MEMBERSHIP OF INDIAN SOCIETY OF HAEMATOLOGY &
                                  TRANSFUSION MEDICINE
                                                                                                      For Office Use:
Secretariat Address:            Dr. H.P.PATI, Hon. General Secretary, ISHTM                           Membership No.
                                Professor of Hematology, Dept. Hematology                             Life         /              annul member
                                A.I.I.M.S.                                                            Date
                                New Delhi- 110029

1. NAME                         First Name                       Middle Name                                 Surname


2. POSTAL ADDRESS : ………………………………………………………………

                                 CITY……………….……STATE ………………………..…..PIN……………

Office Tel. No.________________________                     Residence Tel . No._______________________

E-Mail_________________________________
3. Date of birth                             Nationality                                                    Sex : Male/Female
4. Qualification            Name of University           Qualifying year                                          PHOTOPCOPY
    MBBS

    MD

     PhD                                            ( ATTCH PHOTOCOPY PROOF OF ANY QUALIFICATION)
----------------------------------------------------------------------------------------------------------------------------- ------------------------
5. Professional positions held :

6. Training obtained in Haematology                                         (in India / Abroad)


7. Publications:                                                                      (Attach short list)

     Subscription: ( CHOOSE ONE )

     LIFE MEMBER subscription:                     Rs. 1,500/-


     ORDINARY MEMBER subscription :               Rs. 250/ year (To pay each year to retain membership. Otherwise will expire)


    I agree to abide by the rules and regulations of Indian Society of Haematology & Transfusion Medicine.
I am enclosing DD/No. _______________ Amount in Rs. -------------- __                   __Dtd. _____________________
Bank ____________________________Branch __________________________________________________,
drawn in favor of “Indian Society of Hematology and Transfusion Medicine, Payable at NEW DELHI



Signature of Proposer                                 Signature of Seconder                                 Signature of the Applicant
Name :                                                Name :
Membership No.:                                       Membership No.:                                         DATE:……………………

GUIDELINES:
   1. MUST give your postal address in complete, including PIN

     2.   MUST attach your certificate copies, otherwise membership will NOT be accepted.

     3. Must attach a DRAFT for all out-station (out side Delhi) candidates.

								
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