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Proposal For Membership of The Association: Email

This document contains a membership application form for the UP Chapter of the Indian Association of Pathologists Microbiologists. The form requests information such as the applicant's name, date of birth, gender, nationality, present designation, addresses, academic qualifications, affiliations/honours, publications, total experience, specialization, type of membership applying for, proposers details, and an undertaking agreeing to abide by association rules. The form notes that applications must be accompanied by documents proving identity, qualifications, age, and proof of IAPM/chapter life membership for proposers.

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90 views2 pages

Proposal For Membership of The Association: Email

This document contains a membership application form for the UP Chapter of the Indian Association of Pathologists Microbiologists. The form requests information such as the applicant's name, date of birth, gender, nationality, present designation, addresses, academic qualifications, affiliations/honours, publications, total experience, specialization, type of membership applying for, proposers details, and an undertaking agreeing to abide by association rules. The form notes that applications must be accompanied by documents proving identity, qualifications, age, and proof of IAPM/chapter life membership for proposers.

Uploaded by

Anonymous mKIr49
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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UP CHAPTER OF INDIAN ASSOCIATION OF PATHOLOGISTS MICROBIOLOGISTS

PROPOSAL FOR MEMBERSHIP OF THE ASSOCIATION

1. Name First Name :_______________________________________________________________


(in full)
Middle Name :________________________________________________________________

Surname : ________________________________________________________________

2. Date of Birth: _______________ 3. Age at Application 4. Gender M/F


(Attach Proof)
5. Nationality:
6. Present Designation and Occupation.

7. Address (Tick preferred address for communication)


Official/Clinic/Laboratory Residential

*Pin Code: *Pin Code:


Mobile: Mobile:

*Email:

8. Academic Qualifications, in descending order (Attach Proof) :

S.No. Degree Year of University / Board


Qualification
01
02
03
04

9. Affiliations/Honours:

10. Publications: Books, Chapters in Books, Journals (Attach additional sheet)

11. TOTAL EXPERIENCE IN SUBJECT__________________________________________________________ years


12. SPECIAL INTEREST / SPECIALIZATION:______________________________________________________
13. Membership applied for : Honorary / Associate / Affiliated / Ordinary / Life (Direct) / Life (Existing ordinary Member)
14. This application is proposed by the following who are Life members of UP IAPM Chapter / IAPM parent body

S No. Name & Address of the Proposer Membership No. Signature


01

Mobile No.
Email :

02

Mobile No.
Email :
15. Undertaking: ______________________________________, an applicant to the Associate / Affiliated / Ordinary / Life
Membership of UP Chapter of Indian Association of Pathologists Microbiologists hereby attest that the information’s provided
are true to the best of my knowledge and belief. On acceptance of my membership, I shall abide by the rules of the association and
shall strive to uphold the dignity and objectives of the association. I also agree to pay the membership fees and other dues as
required from time to time.

Date:__________ Place:_______________ Signature______________

* Mandatory fields

FOR USE BY OFFICE

Application received: Complete / Incomplete

Fees Received :

Membership number allotted :

 All applications should be accompanied with the following (mandatory)


o Membership form duly filled, signed, proposed and seconded
o Copy of MBBS and MD/ Diploma degrees
o Certificate of Additional Qualification/Affiliation / Honors
o Proof of age
o Certificate of proof from head of Department in the case of students / Scholar / Residents / Affiliated
member and Indicate IAPM / UP Chapter life membership number of HOD
o DD/ Cheque / Details of NEFT

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