Membership - Pediatric Rheumatology Society

Title

First Name

Last Name

Address
Please provide the full address you would like to use for regular correspondence)
Address

Street

City

State

Other Details (please provide other details like Office Address, designation to the current post and age)

Designation (Designation to the current post)

Age

Office Address

CONTACT Nos: (Including dialing codes)

Res Phone

Mobile Number

Email ID

REMITTANCE DETAILS
(Please enclose with the application form, a crossed demand draft for Rs 3000/- in favor of: "Pediatric Rheumatology Society " payable at Kolkata, INDIA)

Select Mode of Payment
Demand DraftNEFT

DD Number

Dated

Bank Name and Branch

Transaction Number

Bank name and Branch

Date

CV for PEDIATRIC RHEUMATOLOGY SOCIETY membership

Full Name

Age

Gender
MaleFemale

Professional Qualifications

Kindly mention the University and College of MBBS, MD, DCH, DNB, Any specialization in Pediatric Rheumatology.
Why you want to join PEDIATRIC RHEUMATOLOGY SOCIETY

Write five lines on why you want to join PEDIATRIC RHEUMATOLOGY SOCIETY including contribution to Rheumatology (if any)
Publications / Awards (If any)

Write five lines on why you want to join PEDIATRIC RHEUMATOLOGY SOCIETY including contribution to Rheumatology (if any)
Documents to be attached (Following documents in JPG or PDF format)
1. Photocopy of Post graduate degree

2. Recent Passport size Photograph

3. Certificate of attendance of CME/Conference

4. Demand draft Payable at Kolkata, INDIA

Important Information:

1. Fees can be paid either by DEMAND DRAFT or by NEFT

2. In case of DEMAND DRAFT, it has to be taken in favor of “Pediatric Rheumatology Society” payable at Kolkata, INDIA.
(CASH or CHEQUE are not accepted).
Life Members : Rs. 3,000.00 (Rupees Three Thousand Only)

3. In case of NEFT, the amount can be sent to SBI Park circus branch, Kolkata, a/c no 35580222284. IFSC code SBIN0001749

4. Documents to be attached
– Photocopy of Postgraduate Degree
– Recent Passport size Photograph
– CV in the format given below
– Certificate of attendance of CME / Conference
– Demand draft Payable at Kolkata, INDIA.

5. Membership should be proposed by an active life member of Pediatric Rheumatology Society.

4. Incorrect / Incomplete forms shall delay processing.

Dr Vignesh P
Hon Secretary, Pediatric Rheumatology Society
Allergy Immunology Unit, Advanced Pediatrics Centre, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh- 160012
vigimmc@gmail.com

Download Offline Registration Form