Life Membership Form

Endometriosis Society India

Established in 2003

6A & 6F, Neelamber
28B, Shakespeare Sarani, Kolkata – 700017
Phone: (91) (033) 22874463, 28650364
Cell phone:- +91 7044588666
e-mail: endosocindia@gmail.com
website: www.endosocind.org

Founder President :- Dr B N Chakravarty
President: Mr. Pramathes Das Mahapatra, MD, FRCOG, FRCS
Secretary General: Dr. Pradip Kumar Mitra, MD, MNAMS, FICOG, FACS
Assistant Secretary: Dr. Abhijit Ghosh, DNB Treasurer: Dr. Nirmala Pipara, MD,
Members: Dr. Sangeeta Agarwal, DGO, Dr Partha Bhattacharyya, DGO, MS; MRCOG ; Dr Suranjan Chakrabarti, MBBS. DGO, MD (O&G), FICOG

MEMBERSHIP APPLICATION FORM

Contact Form Demo

First Name

Last Name

Full Mailing address

PIN Code

Telephone No.

Mobile No.

FAX

Affiliated Hospital or Company:

Degree/Diploma

University/College

Year

Medical Registrations :

Registration No.

Registering Body

Year

Membership of other Organisations :

Organisation

Type of Membership

Since

Membership categories and fees

LIFE MEMBER: Rupees Five Thousand only ( 5,000.00 )

ASSOCIATE MEMBER (Other Than Medical Doctors): Rupees Two thousand and five hundred only (2,500.00)
INSTITUTIONAL MEMBER: Negotiable

( e.g. Pharmaceutical members )

Mode of payment (put tick mark):

Cash

Cheque

Demand Draft

Please draw cheque (only on any bank at Kolkata) OR demand draft (payable at Kolkata) in favour of
“ENDOMETRIOSIS SOCIETY, INDIA”

Amount Paid:

Rs.

Cheque / Draft Number

Name of Bank and branch

In words

Date of Issue

Details for Bank Transfer

Name of Bank: PUNJAB NATIONAL BANK
Account Holder: Endometriosis Society India
Account Number: 0673010072605 IFS Code: PUNB0067320
Bank Address: Neelamber, 28B, Shakespeare Sarani, Kolkata – 700017.

Donation