APPLICATION FOR MEMBERSHIP

INDIAN COLLEGE OF OBSTETRICIANS & GYNAECOLOGISTS of The Federation of Obstetric & Gynaecological Societies of India 6 th Floor, New Building, Cama & Albless Hospital, Mahapalika Marg, Mumbai 400 001. * Tel : 91 - 22 - 2264 23 08 * Fax : 91 - 22 - 2267 64 05 ----------------------------------------------------------------------------------------------------------------
APPLICATION FOR MEMBERSHIP
I desire to be Member of the Indian College of Obstetricians & Gynaecologists. I hereby apply for the same. I am paying the Membership fee in advance. If duly elected, I shall abide by all the rules and regulations of the College. I hereby furnish my bio-data.
Date of Application __________ Date of Receipt ______________ __________________ (By Office) Signature of Applicant
Name (in Capital) _______________ ________________ __________________ (Surname) (First Name) (Middle Name)
Degrees & Diplomas
University / College / Institution
Year of Qualifying












Permanent Address ____________________________________________________________________ ____________________________________________________________________ _______________________________________ Pin Code No.__________________
Telephone Nos. ________________ _______________ ___________________ _______________ (Residence) (Office) (Mobile) (Pager)
Medical Council Registration Number and date, mentioning the name of the State Register _____________________________
The name of the member affiliate Society : _____________________________
Active member of the Society for : _____________ years, date of joining ________________________
Years of practice in Obstetrics & Gynaecology _________________


All India Obstetric & Gynaecological congresses Attended:
Year
Place







Papers presented as FIRST Author ( Use additional Sheet of paper, if required)(Use additional Sheet of paper, if required)
Year
Place
Title









Papers Published:(Use additional Sheet of paper, if required)
1)__________________________________________________________________________________________
(Title of the Paper)
__________________ ________________ __________________ __________________ Name of the Paper Year Volume No Pages Nos.
2)__________________________________________________________________________________________
(Title of the Paper)
__________________ ________________ __________________ _________________ Name of the Journal Year Volume No Pages Nos.
3)__________________________________________________________________________________________
(Title of the Paper)
__________________ ________________ __________________ _________________ Name of the Paper Year Volume No Pages Nos.
Proposed by : _______________ ________________ __________________ (Surname) (First Name) (Middle Name)
Address : ____________________________________________________________________________________________________________ Pin Code No.______________
Member of:_____ _________________ Signature of the Proposer _____________
Seconded by : _______________ ________________ __________________ (Surname) (First Name) (Middle Name)
Address : ____________________________________________________________________ ___________________________________________ Pin Code No.______________
Member of :(Ob/Gyn Society) _________________ Signature of the Proposer ______________
------------------------------------------------------------------------------------------------------------------------------------------------------ To be filled by the Member Society (Certificate by the Member Society)
This is to Certify that Dr.____________________________________ is a continuous active Member of the Society for the last ___________ years and holds the qualification mentioned above.
__________________________ Signature of the President
Seal
_____________________________Signature of the Hon.Secretary
----------------------------------------------------------------------------------------------------------------------------- To be filled in by the College Office
Serial No._________ Date when application & Payment received _____________
Amount Rs.______________ by Cash / Cheque /Draft
Receipt No._____________ Date ____________
Date when application is approved by the Governing Council _________________
Remarks ___________________________________________________________________ ___________________________________________________________________________
Date and Place of the Convocation when Fellowship Conferred ___________________________
__________________________ President, FOGSI
__________________________ Chairman, ICOG
_____________________________Hon.Secretary, ICOG
-----------------------------------------------------------------------------------------------------------------------------
The eligibility for the Academic Fellowship is as follows : ( Kindly attach Certified copies for proof ).
Holding of MD or equivalent qualification for 3 years.
Membership of FOGSI for 5 years .
Publication of 3 papers in any recognised Journal of Obstgetric & Gynaeclogy of india
Attendance of 2 FOGSI Congresses
Presentation of at least 2 papers at FOGSI Congresses as First Author.
Membership Payment of Rs.5,500/-.