MEMBERSHIP FORM
Geriatric Society of India ®
MEMBERSHIP FORM
Geriatric Society of India ®
Dr./Mr./Ms. ………………………………………………………………………...…………………………………………………………
Designation ………………………………………………………………………...……………………………………………………
Mailing Address ………………………………………………………………………...…………………………………………………….
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Pin.........................Tele:.......................Fax...........................Email:............................................................................... *Proposed By ..........................................
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*Seconded By .........................................
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*Kindly send your Copy of MCI Registration Certificate in the absence of getting Proposed and Seconded
Life Membership Fee : Rs. 3000/- (For Indian Member)
[Demand draft in the name of Geriatric Society of India, Payable at New Delhi (INDIA)]
Date....................................... Signature.............................................
Please take a print of this form and post mail only the filled in form and
demand draft to
Secretariat:
Dr. O. P. Sharma,
K-49, Green Park,
New Delhi - 110 016
INDIA