MEMBERSHIP APPLICATION

Name: Email:
Address:
Phone: Gender: MALE   FEMALE  
Present Designation: Speciality:
Name of the Institute/Hospital: Experience:
Medical Council registration number:   

MAILING ADDRESS

Address:
Pincode: City:
State: Country:
For: Life time Membership Rs 5000/-  

PAYMENT PARTICULARS

Account name - Tamilnadu Medical and Pediatric Oncolotist Society, Account Type - Current Account Number : 500200038175013
IFSC Code : HDFC0001068, Bank Name - HDFC Bank, Branch : Kalapatti Road Cheque or DD should be drawn in favour of €śTAMPOS €ť

Cheque/DD No: Date:
Amount: Bank:

Note: You can register offline by sending duly filled membership form along with Cheque/DD drawn in the favor of: "Tamilnadu Medical and Pediatric Oncologist Society". Address to be sent - Dr.N.Sudhakar, Royal Care Institute of Oncology, Royal Care Super Speciality Hospital, 1/520, L&T Road, Neelambur, Coimbatore-641062.