Indian Society of Interventional Radiology

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Membership Form

Membership

Full member (Practising vascular & interventional radiologist)	Rs. 3,000
Associate member (Radiology)	Rs. 300
Associate member (General)	Rs. 500
Student member	Rs. 300

Membership Form:

Please fill in the following form and click the 'Submit' button at the end.

Name:

Date of Birth:

Year: Month: Date:

Present Designation:

Hospital/Institute:

Address:

City:

Pin:

Tel:

Fax:

Email:

Medical Regn No.

Issue Date: Place:

Professional Qualifications
	Degree	College	University	Year
Under-graduate
Post-graduate
Others

Prof Society Membership(s):

Recommended by: (Names of two full members of society who have agreed to sponsor you)

Application Type: (Select One)

Life Member: Associate Member Radiology:
Full Member: Honorary Member:
Associate Member Radiology: Emeritus Member:

I agree to abide by the constitution and by-laws of the society and by such rules and regulations as may be enacted from time to time.

Date:

Place: