Membership Form

NSSI Membership Application Form

Neurological Surgeons' Society of India

Application for Membership

[forminator_form id="985"]

Payment can also be made by NEFT/Bank Transfer/IMPS. The Details are as follows : Bank ICICI Bank, Branch C Scheme, Opposite SMS Hospital, Jaipur. Account Holder’s Name : Neurological Surgeons’ Society of India. Account No : 675001700384. MICR Code No. 302229016. IFSC/RTGS ICIC0006750

Membership Form

Name (Block Letters) *

Date of Birth *

Father's Name *

Permanent Mailing Address *

Pin *

Email *

Phone No (With STD code)

Fax No

Mobile No *

Qualifications and Institute *

Appointments, Post and Experience *

Other interest

Membership (Please select an appropriate option) *

Amount

D.D./Cheque at par No

Bank

In case of Electronic Money Transfer please quote UTR No (Attach a copy)

Payment can also be made by NEFT/Bank Transfer/IMPS. The detail are as follows: Bank ICICI Bank Branch C Scheme Opposite SMS Hospital Jaipur Account Holder’s Name: Neurological Surgeons’ Society of India. Account No 675001700384. MICR Code No 302229016. IFSC/RTGS ICIC0006750

Please attach you short cv * Acceptable CV File-size: Maximum 512kb Only Acceptable Filetype: Word or PDF Only Place * Date *

Signature of Applicant *

Applicant' Photograph * Acceptable Photo size: 1Mb with 350 pixels (Width) X 350 pixels (Height) Acceptable Filetype: PNG, JPG, and JPEG Only

DETAIL OF PAYMENT

Life Member Rs.15000/- in one installment, Associate Member (DNB,MCh Students) 15000/- in one installment(Life Membership Reclassified after producing Degree/Diplome of MCh/DNB) Allied Member 10000/- in one installment, Foreign Members 400 USD to be drawn in favor of Neurological Surgeons Society of India. Dully filled membership application along with fee is to be sent to:-Dr. R.S.Mittal 105 Virndavan Vihar Colony Near Shyam Nagar Police Station Nirman Nagar Ajmer Road Jaipur 302019 Phone:-0141- 2810950,+919414244866(M) email dr_mittal@hotmail.com, nssi.india@gmail.com

Name of Bank: ICICI Bank
Opposite S.M.S Hospital, SAWAI RAM SINGH ROAD, Jaipur
A. /C HOLDER – NEUROLOGICAL SURGEONS SOCIETY OF INDIA
A/C No – 675001700384
IFSC CODE – ICIC0006750
MICR CODE – 302229016