subscription form

SRIGANGANAGAR OBSTETRICAL & GYNECOLOGICAL SOCIETY

SRIGANGANAGAR (RAJ.)- 335001

Name: Dr. (Mr./Mrs./Miss) ____________________________________________________

Date of Birth: ____/____ /_____ Date of Marriage _____/_____/_______

Address of Correspondence: _____________________________________________________

__________________________________________________________________________________

________________________________________________ PIN_______________________

Telephone ___________ (Off.) ____________ (Res)

Email address : ____________________________________________________________________

Qualification: M.B.,B.S (Year of Passing) _____________________

D.G.O. M.D./M.S. (Year of Passing) _____________________

Others: _____________________

Raj. Medical Council Reg. No.:_______________________________

Area of Interest: _______________________________

Practice: Govt./Private-Clinic/ Hospital/Consultation

Name of Spouse: Dr.__________________________________________________________

Qualification of Spouse: M.B.B.S/M.D/M.S/Other__________________________________

Ordinary Member : Rs. 750/- (Please add Rs. 50/- for outstation cheque)
Cheque/D.D. to be made in name of
SRI GANGANAGAR OBSTETRICAL & GYNECOLOGIST SOCITEY

Please give a photocopy of proof of identification as ration card / driving license / voter card / passport

Contact Person:
President Secretary
Dr. Shambhu N. Gupta Dr.Reeta Bedi
City Hospital, 45-Model Colony, 78-P Block
Sri Ganganagar (Raj.) 335001 Sri Ganganagar (Raj.) 335001
Ph. 0154-2461641(O) 9214179841 (M) 2473482