Details of payment : Cash/Demand Draft/Cheque/Online
   North Zone Chapter
   Urological Society of India
   Membership Application Form
Category of applied for:
Name (Use Block Letters) : First Name
Middle Name
      
Please tick the appropriate box for preferred address for communication:           
Residence Address Office Address Loading.

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Address Address
Pincode Pincode
Tel.(Res.) Tel.(Office)
Email Mobile No.
Fax No.
Date of Birth
Present Appointment & Designation
Designation Institute Year of Joining
Acedemic Qualifications:
Degree/Diploma Year of Passing University
Training in Urology:
Training in Urology Period of Training University/College/Hospital
USI Member: Yes/No
Only to be filled if you are USI member
If Yes, USI No. Select Category
Membership Fee (Life) :INR.5,000/- + 15% S.T. = INR 5750 Overseas (Excluding SAARC Countries) : US$ 287.5/-
  Select Category
Dated
Drawn on (Please add Rs. 35/- for oustation cheques)
*
Note :
  • Only fullmembers of the parent body, USI, are eligibleto become full members of Zonal Chapters. Full members of other zones can become associate members of North Zone. A member cannot be a full member of two different zones.
  • Only life membership is accepted.
  • If the payment is madeby draft/cheque should be account payee and drawn in favour of 'North Zone Chapter-Urological Society of India', it payble in New Delhi.
Place Date
[Please attach self-attested copies of the documents for qualification and training in urology.]