Membership Form
Society of Andrology: India
Life Membership Form
(Update your contact information, if you are already a Life Member)
Name: M/F/Dr. /Prof. _________________________________________________________
Date of Birth________________________________________________________________
Institute/Present Position ______________________________________________________
___________________________________________________________________________
Field of Specialization: Applied Research Basic Research Clinical Practice.
Education:
List the institution you have attended and degrees you have received. Include Post-doctoral Fellowships.
_________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Address Office:
_________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Country _____________________________ PIN Code ______________________________
Address for Communication:
______________________________________________________________________________________________________________________________________________________Telephone: (Office) __________________________(R) _______________________________
Fax No. _____________________________________
Mobile No.: __________________________________
E-Mail: _____________________________________
Website ____________________________________
Date: ______________________________________ Signature
The Treasurer
Society of Andrology: India
SLNG Institute of Physiotherapy
Near Jogmaya Mandir
Between II C & IInd D Road
Sardarpura, Jodhpur 342003 (Rajasthan) India
Phone:91-9829025894,
0291 2613433, 2638928
E-mail: ratanvyas56@gmail.com
Life Membership Fee: 2,500/-
Student Member : 1,500/-
Foreign : US $250
The payment RTGS, Electronic Money Transfer (Demand Draft or multicity cheque) should be drawn in favour of Society of Andrology: India.
⦁ Name of the Bank – Bank of Maharashtra
⦁ Branch : Paota, Mandore Road, Jodhpur, 342003 Rajasthan, India.
⦁ Name of the Account : Society of Andrology : India
⦁ Account Number : 20153614531
⦁ MICR Code: 342014002
⦁ IFSC Code : MAHB0000708
⦁ Swift Code : MAHB-INBBJPRP1