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TELEOPHTHALMOLOGY SOCIETY OF INDIA
Membership Registration Form
Name:
Upload Profile Picture
Father Name:
Age:
Sex:
Male
Female
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
Email:
tosi.india@gmail.com
Website:
www.tosi.org.in
Signature of the applicant
I agree to
terms & conditions.