Membership Form for Gujarat Orthopaedic Association
Please supply the following information
# denotes a compulsory field. If the
information in these categories is not supplied, the form submission will be
rejected.
PERSONAL DETAILS
# Recent Passportsize
Colour Photograph
Life Membership Full
Membership Associate Membership
# First Name
Middle Name
#Last Name
#
Date of
Birth
#
Qualifications
#
Year
Passed Post-graduation
#
Institute
of post-graduation
CONTACT DETAILS
#
Work address
Work Address
(Cont'd)
#
City /
Town
#
Pin Code
#
Work
phone (with STD)
#Home
Address
Home
Address (Cont'd)
#City / Town
#
Pin Code
#Home Phone (with STD)
Fax
Mobile / Cellular Number
Email
address
URL
OFFICIAL AND ACADEMIC INFORMATION
Experience in orthopaedics and
publications
Member of IOA?#
Yes
No
IOA membership Number
Medical Registration Number and Place
#
PAYMENT DETAILS
Cheque or Draft no.
#
Drawee
Bank Name
#
Dated
#
Amount
(Rs.)
#
REFERENCES
Proposed by
#
Seconded
by
#
I have read the constitution of
the Gujarat Orthopaedic Association. By submitting this application, I pledge
to abide by it.
Signature of Applicant with
Date
Application for
Membership of
GUJARAT ORTHOPAEDIC
ASSOCIATION
The Gujarat Orthopaedic
Association is a chapter of " Indian Orthopaedic Association". The object of
the association is the advancement of science, art and practice of orthopaedic
surgery. The association has yearly conference in the second or third week of
February. It also conducts postgraduate lecture and fellowship
programmes.
Life member and full
members may be elected from those who hold the postgraduate degree in
orthopaedic and/or its equivalent, or from surgeons practicing orthopaedics
exclusively.
Associate member may be elected
from
Those who hold
Diploma in orthopaedics
Those who are in
training in orthopaedic surgery
Those in allied
surgical specialties or medical branches related to orthopaedic surgery.
All the applications must be proposed and seconded by two full / life
members of the association. Annual subscription for full and associate members
are due on 1st April of each year and are payable in advance.
SUBSCRIPTION
FEES
Category
Fees
Admission
Life Member
Rs. 1500/-
* (Please add Rs. 10/-
towards bank charges)
Demand Draft must be in favour of "GUJARATH ORTHOPAEDIC
ASSOCIATION" payable at "Ahmedabad"
If you wish to apply by post, the application form with
the above information should be sent with the payment (D/D) directly
to:
Dr. Ashit K. Mehta
Honorary Secretary, Gujarat Orthopaedic
Association Anusha Fracture & Orthopaedic Hospital,