First Name * Middle Name Surname *
Address for Communication (where postal mail will be sent) *
City * State *
Permanent Address *
City * State *

Phone (including STD code)
Office * Residence
Mobile * Email *
Present employment status *
Registration No. * MCI / Name of State Medical Council *
Upload Scan Copy of DD *

S. No.

Qualification * University * Year *
Proposed By *
Membership No
Signature _____________________
Seconded By *
Membership No
Signature _____________________

Declaration by the applicant

I shall abide by the regulations of the society in force and any subsequent amendments made from time to time. All information given above is true to the best of my knowledge.

I am enclosing a Demand Draft wide No. dated for the amount Rs.1500.00 in favour of North Zone Ophthalmological Society, payable at Chandigarh.

Please post the completed form along with true copy of DD to
Dr. Suresh Kumar Gupta
Hon. Gen. Secy. NZOS
Department of Ophthalmology
GMCH-32,Chandigarh-160030							                              Signature of Applicant _____________________
Email & Mobile :, 9646121588

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