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OCULAR TRAUMA SOCIETY OF INDIA

(O.T.S.I.)

MEMBERSHIP APPLICATION
Contact Us by filling the form below or send us an e-mail

Your Name :-

Surname:

Firstname: Middlename:
Sex(M / F): Date of Birth:
Spouse Name: Wedding Anniversary:
Qualifications(Degree/Diploma/DNB):
University: Year of Passing:
Fellowship: Academic Interest:
Year: Institute:
Mailing Address:
Phone: *Your Email :
Work Experience:
* Country : Year:

Present place of work:

Professional Membership(AIOS/DOS/Others):
Publications in last 3 years. Total:

Proposed by:

Address:

Signature:

Seconded by:

Address:

Signature:

Details of Payment:-

DD of Rs. 2000 No.: Signature of the applicant:

Issuing Bank: Date:

In favour of *Ocular trauma society of India* payable at Mumbai. Please send the draft to

Dr. S. Natarajan
General Secreatory - O.T.S.I.
Aditya Jyot Eye Hospital
Ashirwad 168-D, Vikas Wadi
Dr. Ambedakar Road, Dadar T.T. Mumbai-400014
Tel.: 4168739, 4182251/53, 4165533(6 Lines)
Fax: (91-22) 4141946, email- ajeh@vsnl.com

Encl: A. Demand Draft
B. Curriculam Vitae
C. Xerox copies of certificates elated to training and attested.

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Copyright 2007 Ocular Trauma Society of India Pvt.Ltd. .

12/27, West Patel Nager, New Delhi - 110 088, INDIA. TEL: 25882129, 25887228, 25882822 ~ FAX:

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