1. No category

APPLICATION FOR MEMBERSHIP
OF
KERALA ORTHOPAEDIC ASSOCIATION
I wish to apply for
LIFE/ASSOCIATE Membership of the KOA
(Life: Rs:3100 plus Rs 50 for out station Cheque, in favour of KeralaOrthopaedic Association payable at Ernakulam), PG Rs 400
(Rs 100 of 3100 for membership of OASIS)
(Please type or use Capital letters)
Please affix a
passport size
photo
Subscription paid
Rs:………………
by cash/cheque/DD No…………
Drawn on……………………….
Dated
……………………….
Name in Full …………………………………………………………………….
Designation …………………………………………………………………….
Organisation or Hospital
…………………………………………………….
1.Present address
…………………………………………………………….
…………………………………………………………….
••• •••
•••••
••••••••
Pincode
Tel: Stdcode
No.
Mobile:
E-Mail:
2.Permanent address: …………………………………………………………….
…………………………………………………………….
Pincode
Mobile:
Mailing address 1/2/other
Date of Birth
:
••••••Tel: stdcode••••• No. ••••••••
••••••
E-Mail
Blood Group:
Wedding Anniversary:
Qualifying M.B.B.S :
Institution
:………………………………………….
Year:………….
University………………………………
Post Graduate Diploma:
Institution
:…………………………………………..
Year :………….
University……………………………….
Post Graduate Degree :
Year : ………….
Institution
:…………………………………………… University ……………………………….
Other
:…………………………………………….
Medical Council & Registration Number:
Member of Indian Orthopaedic Association:
Yes/No
Member of Indian Medical Association
Yes/No
Experience in Orthopaedics and Publications (Please attach)………….………………………………..
Date:
Signature
Proposed by
Member Kerala Orthopaedic Association
Signature
Secretariat:
The Kerala Ortho House, Eastland Enclave, Block II, Flat 505, Cochin – 682 020
Tele:_ 0484-2320175, Email
: [email protected]
Note: Mandatory to Submit Orhopaedic Degree Certificate along with the application. ( D. Ortho,/ MS
Ortho or DNB Ortho etc.)