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

First Name

Last Name

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PIN Code

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Year

Medical Registrations:

Registration No.

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Membership of other Organisations:

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Membership Payment

LIFE MEMBER: Rs. 5,000

ASSOCIATE MEMBER: Rs. 2,500

INSTITUTIONAL MEMBER: Negotiable

Mode of payment (tick one):

Cash
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Cheque/DD in favor of “ENDOMETRIOSIS SOCIETY, INDIA”, payable at Kolkata

Amount Paid (Rs.)

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Date of Issue

Name of Bank and Branch

Details for Bank Transfer

Bank: PUNJAB NATIONAL BANK

Account Name: Endometriosis Society India

Account Number: 0673010072605

IFSC Code: PUNB0067320

Branch: Neelamber, 28B, Shakespeare Sarani, Kolkata – 700017

Donation

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