Adolescent Pediatric Chapter Indian Academy of Pediatrics

Membership

Download Membership Form

Application Form For Life Membership
IAP Chapter On Adolescent Pediatrics

To
Dr. Sukanta Chatterjee, Secretary
IAP Chapter on Adolescent Pediatrics
889A, Lake Town
Kolkata - 700 089
Tel : 91.33.2534 5909; M : 91.98302 75685
E-mail : sukantachatterjee@hotmail.com

Dear Sir,

I wish to enroll myself as a Life Member of IAP Chapter on Adolescent Pediatrics. The details are
given below :

1. Name : Surname :

First Name :

Middle Name :

2. Sex :

3. Central IAP Membership No. :

4. IAP Non Member (Phychiatrist/Phychologist/Counsellor/Teacher) :

5. Corresponding Address :

6. Designation in Institute (If any) :

7. Academic Qualification (s) :

8. Phone No. Residence :

Office/Chamber :

9. Fax No. :

10. Email :

11. Date of Birth :

(dd.mm.yyyy)

12. Bank Draft/Cheque No. :

Name of Bank :

Branch :

Amount :

Cash :

Date :

(dd.mm.yyyy)

Life Membership Fee : Rs. 1050
DD to be drawn in favour of “Adolescent Chapter IAP” payable at Kolkata

Download Membership Form
to send the filled up offline application along with the draft amounting Rs 1050
to The Secretary in the above mentioned address