Glaucoma Society of India

GSI Life Membership Form

Applying for *

Title *

Personal Information

First Name *

Middle Name

Surname *

Gender *

Date of Birth *

Mobile No.*

Alternate No.

Email *

Upload Passport Size Photograph* Image size should be 600 X 400 Pixels and not more than 200KB.

Upload User Signature* Image size should be 131 X 60 Pixels and not more than 200KB.

Address

Address1 *

Address2 *

Address3

Country *

State *

City *

Pin Code *

Qualifications

Degree(i.e. MBBS) *

Full University *

Year of Passing *

Copy of Degree * file size not more than 300KB.

Degree of Post-Graduation in Ophthalmology *

Full University *

Year of Passing *

Copy of Degree * Maximum File Size Limit is 300KB

Registration certificate of Medical Council with PG qualification *

Full State*

Year of Registration **

Copy of Registration * Maximum File Size Limit is 300KB

*FOR FULL LIFE MEMBERSHIP: Have you done any formal training for a period of 6 months or more (Fellowship/ Senior Residency) in a Glaucoma Unit?

Yes No

Place *

Institution *

State Date *

End Date *

Upload Certificate *

If you are a member of any Ophalmological Society, please funish details below :

Society Name

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Proposed By

Membership No *

Name*

Mobile No.*

Email Id*

I have taken consent from Proposer

Seconded By

Membership No *

Name*

Mobile No.*

Email Id*

I have taken consent from Seconder

Government ID Proofs

Please select id proof which you wish to upload *

Upload Certificate *

Amount : INR 6180

An Internet Handling Charges of Rs. 174 will be applied. Details will be shown at the checkout page.

Declaration: (TERMS AND CONDITIONS) I have read and understood the terms and conditions and agree to abide by them. I shall respect and follow the constitution of Glaucoma Society of India (The Society) in letter and spirit along with any future changes made in rules, regulations and bye laws of the society. I understand that any anti-society or any unlawful activity on my part may lead to loss of my membership or imposition of any other penalty/ punishment in accordance with the bye laws of the society prevailing from time to time.

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Reg. Fee
6180/-
Internet Handling Charges
174 /-

Enter the contents of image :

GSI Life Membership Form

Personal Information

Address

Qualifications

Which Type of Practice do you have:*

What percentage(%) of your practice consists of Glaucoma Patients ?*

Proposed By

Seconded By

Government ID Proofs

Amount : INR 6180

Account Login Detail

Payment Summary

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