Indian Society for Pediatric and Adolescent Endocrinology (ISPAE)
Application Form for Life Membership

First Name:    
Middle Name:
Last Name:    
Sex: Male Female   
E-mail id:    
Date of Birth (DOB):           (DD/MM/YYYY format)
Nationality:   Indian Other   
IAP membership: 
Professional Designation:  
Official Address: 
Pincode:     
Phone: 
Mobile:     
Home Address: 
Pincode:     
Phone: 
Mobile:     
Preferred address for correspondence:   Home Office  
Qualifications University Qualifying Year
MBBS
DCh
MD (please specify Medicine/Pediatrics/Other )
Other (Degree and subject)
Special area of interest in endocrinology:
Thyroid                                         Pituitary                                         Adrenal
Growth                                         Diabetes                                        Gonad
Puberty                                         Calcium / Bone                              Other
Present position:
Clinical            Government Private
Teaching          Yes No
Research         Government Industry
Trainee 
Membership of any other medical societies: 
Details of payment cheque: 
Date(dd/mm/yyyy): 
Bank: 
Amount(in INR): 

Cheque of Rs 3000.00 (for life members) and Rs. 1500.00 (for associate ,members) is to be made in favor of "Indian Society for Pediatric and Adolescent Endocrinology, A/c # 000701255104", and dropped in any ICICI Bank drop box in your city. The membership form should be filled online (with payment details) and the pdf generated should be emailed to Dr Rajni Sharma, Joint Secretary, ISPAE at drrajnisharma@yahoo.com. A copy of this should also be emailed to the Secretary Dr Anurag Bajpai at dr_anuragbajpai@yahoo.com

Declaration: I agree to abide by the rules and regulations of the Indian Society for Pediatric and Adolescent Endocrinology in force from time to time.


Place:
Date:



Applicant's Signature