ISBMR Life Membership Application Form ISBMR Life Membership Application Form Date: First Name: Middle Name: Last Name: Date of Birth: Degree: Designation: Name of Hospital: Mailing Address: City + Code: State: Phone Nos: Mobile No: Email: Present University / Institutional / Organizational Affiliations (Attach separately if needed) Appointment 1: Institution 1: Date: Appointment 2: Institution 2: Date: Appointment 3: Institution 3: Date: Publication (List One) (Attach separately if needed) Payment Details Cheque/DD No.: Dated: Amount (Rs.): Amount in Words: Drawn on (Bank Name): Life Membership Fee: Rs. 5,000 / US$ 250 / Pound Sterling 200 (inclusive of 18% GST) Bank Details: A/c Name: Indian Society for Bone and Mineral Research A/c No.: 054701002851 Bank Name: ICICI, SCO 219, Sector 36 D IFSC Code: ICIC0003417 GSTN No.: 07AAAAI1439C1Z7 President / Chief Executive Officer - ISBMR Indian Society for Bone & Mineral Research # 2247, Sector 38C Chandigarh - 160036 Website: www.isbmr.org Email: info@isbmr.org, isbmrindia@gmail.com Submit Application
