Membership Form

Full Name (Dr / Mr / Ms / Mrs) :

Sex :

Age :

Date of Birth :

Blood Group :

Qualification :

Specialization :

Registration No. :

Designation :

Special Interest in Field of Pain :

Permanent Address :

Pincode :

State :

Phone :

Correspondent Address :

Pincode :

State :

Phone :

E-mail Id :

Mobile No. :

I agree to abide by the rule & regulation of Indian Society for The Study of Pain.
I wish to join INDIAN SOCIETY FOR THE STUDY OF PAIN as life member/Associate Member and enclose Cheque / D.D.

Cheque/D.D. No. :

Draw on Date :

Bank :

Rs :

(Drawn in favor of Indian Society for The Study of Pain ) towards subscription for the life Membership

Date :

Signature of Applicant :

1. Sponsor's Signature:

ISSP LM No. :

Sponsor's Name :

2. Sponsor's Signature:

ISSP LM No. :

Sponsor's Name :

✓ Life Membership Fees:   Within India: Rs 5000/-
                                                  Outside India: US $ 250
✓ Associate Membership Fees:   Within India: Rs 3500/-
                                                  Outside India US$ 150
✓ P.S. Outstation Cheque should be accompanied by Rs.100/- extra as bank charges.
✓ Send two passport size photographs for I card.
✓ Cheque / AD in favour of "Indian Society for The Study of Pain" payable at Hyderabad.

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