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TELEOPHTHALMOLOGY SOCIETY OF INDIA

Membership Registration Form

    Name:
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    Father Name:
    Age:
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    Qualification(Please submit copy of the certificate):




    Date of Birth:
    Permanent Address:
    Address for correspondence (If other than permanent):
    Proof of ID Aadhar 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: +91-9437069633
    Website: www.tosi.org.in
    Signature of the applicant
    I agree to terms & conditions.