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Indian Academy Of Neurology
   
Application For Membership Life Member/Associate Member/Life Associate Member
 
* Name
    First Name                                 Middle Name                        Last Name  
 
* Date Of Birth
  Age
  Sex
  Mailing Address
  City
  State
  Country
  Pin
* Permanant Address
* City
* State
* Country
* Pin
  Contact No
  Fax
* Mobile No
* Email  
  Website
  Qualifications
* Past Appointment and Experience in Speciality
* Designation and Present Appointment
* Photo Scan
  Certificate Scan      
  Certificate Scan      
  Certificate Scan      
  Signature Scan
  Demand Draft Scan
* DD No
* DD Date  
* Drawn on Bank
* Place
* Date
* Proposed By
* Seconded By
       
 
Note : Please attach Scan Copy                 
           1)Neurology DM/DNB/Other Degree certificates                    
           2)Signature of the applicant
            3)Two Photographs
           4)Copy of Demand Draft
           5)For AM Membership residency Certificate residency from Head of Department.