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    TELEOPHTHALMOLOGY SOCIETY OF INDIA

    Membership Registration Form

    Name -


    Father's Name - Age: Sex: M/F


    Qualification -

    (Please submit copy of the certificate) Date of birth -

    Permanent address- Address for correspondence-(If other than permanent)


    Proof of id - Adhar No - PAN No -Membership category

    Membership category

    Membership fees

    1

    LIFE MEMBER

    Rs 5000.00

    2

    OVERSEAS LIFE MEMBERS

    $500

    3

    OVERSEAS LIFE MEMBERS (SAARC Countries)

    $100

    4

    ASSOCIATE MEMBER

    Rs 4000.00

    5

    INDUSTRIAL MEMBER (Applicable for 5 years)

    Rs. 50000. 00


    Admission Fee Rs. 1000/- (Rupees One thousand only) at the time of admission for all category of members


    Payment details


    NEFT/DD / Cheque No.: …………………….Date: (Add. Rs.50/- if outstation cheque) Name of Bank: Branch:


    Signature:                  


    Send the detail by post to : Tele ophthalmology Society of India, C/o Prof BNR Subudhi, Hon Secretary, Ruby Niwas, New Bus Stand Road, Berhampur, Ganjam, Odisha- 760001


    Mobile: 94370 69633

    Email: tosi.india@gmail.com Website: https://tosi.org.in


    Signature of the applicant