MEMBERSHIP FORM

                                      MEMBERSHIP FORM

                              INDIAN ACADEMY OF PEDIATRICS – U.P. STATE BRANCH


Personal Information

First Name _______________ Middle Name _______________Last Name _______________________

Complete Mailing Address:______________________________________________________________

City: ________________________ Pin Code: ____________ STD Code: __________________________

Phone Residence: _________________________ Phone Clinic: ________________________________

Mobile No.: ______________________________Email ID: ____________________________________

Are you a member of Central IAP: Yes/No: _______ Central IAP Number: _________________________
 
        Qualification               Year of Completion            Institute
 MBBS    
 DCH    
 MD    
 DM    
 Other (specify)    


Present Attachment: Teaching(1), PMHS(2), Corporate Hospital(3), Private Practice(4), Other(5)

Remarks (if any)__________________________________________________________________

Date:                                                                                                                      Signature

Place:
____________________________________________________________________________________________

Membership Fee Life Membership Rs 3500, Student Membership Rs 2000

Bank Details “Indian Academy of Pediatrics Uttar Pradesh” Axis Bank Meerut, (Account No
916010083448147 ,IFSC UTIB0000177)

Please mail the completed form to:

Dr. D. M. Gupta, Honorary Secretary
Pankhuri Hospital,34/105 A Golgadda,
Behind Kashi Roadways Depot
Varanasi – 221001
E-mail: dhirajmg@gmail.com
Mobile: 9415448699,0542-2441838

MEMBERSHIP FORM

MEMBERSHIP FORM

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