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Membership > Online MOA Membership

   
(Fields marked * are mandatory)
      

   
Draft No.: * of Rs. 3000/-
 
  OR
Cheque No.: * of Rs. 3150/-
  Payable At- Kolhapur.
Banker's Details : *
OR
Transaction ID : *
Maharashtra Orthopaedic Association
State Bank of India, Rajarampuri, Kolhapur.  [A/C No. 30361161816]
 
  My Personal Details are as follows
 
Name : * Surname * Name * Father's/Husband's Name *
 
Qualifications: Degree / Diploma

1.  

Year :
 
Institute / University :

2.  

Year :
Institute / University :
Residential Address :

Tel. No. * :

Fax No. :

  

Mobile * :

E-mail ID * :

Website :
Hospital Address :
    (Clinic/Consulting)

District :   

Hospital Tel. No. :
Attachments :
Special Interest : Trauma
 Spine Surgery
Arthroscopy
 Joint Replacement
 Illizarove
Hand Surgery
 
Proposed by Life Member : Dr.

Address :

Tel No. :
Seconded by Life Member : Dr.

Address :

Tel No. :
IOA Member : Yes    No
If Yes - IOA No. :
   
   
   

 

Note : Demand Draft in favour of "Maharashtra Orthopaedic Association" payable at Kolhapur.

Important : Your membership is subject to ratification in the subsequent AGM of the Association  during MOACON. Allotment of membership number will follow the ratification.

IMP: Please attach one passport size photograph with application form and copies of Qualification Certificate..


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