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Member Application - The Association of Surgeons

This document contains an application form for membership in the Association of Surgeons of India (ASI). It requests personal details like name, photo, contact information, education and professional details, and payment details. It provides information on membership benefits like awards, social security schemes, and professional protection. It also shares contact details for the ASI head office and queries, and highlights the history and goals of ASI to bring together surgeons for experience sharing and skill enhancement.

Uploaded by

Craj Raj
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
27 views1 page

Member Application - The Association of Surgeons

This document contains an application form for membership in the Association of Surgeons of India (ASI). It requests personal details like name, photo, contact information, education and professional details, and payment details. It provides information on membership benefits like awards, social security schemes, and professional protection. It also shares contact details for the ASI head office and queries, and highlights the history and goals of ASI to bring together surgeons for experience sharing and skill enhancement.

Uploaded by

Craj Raj
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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HEAD OFFICE QUERIES

+91 44 25385584 [email protected]

HOMEPAGE / MEMBER APPLICATION

Download Printable Format

ASI Member-
ship Cate-
ASI Member-
FAIS Form gories & Sub-
ship Form
scription De-
tails

ASI Membership Form


Apply online to become member of ASI

All fields are mandatory

Personal Information

Name *

Dr Calvin Roby
Title First Middle Last Suffix

Sex *

Male

Female

Upload your photo *


Choose File 1 photo

Upload your passport size photograph (image file only), in jpg, jpeg, png
format.

Qualification *

Doctor

Email *

[email protected]

Mobile Number *

7975997012

Date of Birth *

27 / 12 / 1994
DD MM YYYY

Permanent Address

Detailed Address With Pin Code is Compulsory.

Address *

Kaniyankuzhil po Velladu alakode kannur 670571


Street Address

Address Line 2

Kannur Kerala
City State / Province / Region

670571 India
Postal / Zip Code Country

Detailed address with pin code is compulsory.

Institute Address

Department

Surgery

Institution

Kanachur institute of medical sciences

Address

Kanachur hospital Deralakatte mangalore karnataka


Street Address

Mangalore Karnataka
City State / Province / Region

575018 India
Postal / Zip Code Country

Default Address for Communication


What should be default address for communication. Required for
document and ID card dispatch etc.

Default Address for Communication *

Institute Address

Permanent Address

Other (Type Below)

Education

College / University

Institution

United Indian school

Degree Awarded

PUC

Date

7 / 03 / 2012
DD MM YYYY

Medical School - MBBS

Insttution

Ks Hegde medical academy

Degree Awarded

Mbbs

Date

30 / 12 / 2017
DD MM YYYY

P.G. Training (MS:DNB)

Institution

Kanachur institute of medical sciences

Degree Awarded

MS

Date

/ /
DD MM YYYY

Super Speciality Training (MCH/DNB) if any...

Institution

Degree Awarded

Date

/ /
MM DD YYYY

Medical License

Registration Number *

127432

Date

07 / 03 / 2019
DD MM YYYY

Name of 2 Referees ( who are Full life ASI members )

Name

Yatish G Hegde
First Middle Last

ASI Membership No

23872
Must be between 1 and 5 digits. Currently Entered: 5 digits.

Mobile

Email

Name

First Middle Last

ASI Membership No

Must be between 1 and 5 digits. Currently Entered: 0 digits.

Mobile

Email

Upload your Highest Degree and Registrtion


Certificates

Highest Degree Certificates *


Choose File no file selected

You can upload maximum of 10 files with a size limit of 1MB each.

Medical Council Registration Certificate


Choose File no file selected

Upload Medical Council Registration Certificate. Size limit is 1 MB.

GST Details
If you wish to Claim GST Invoice, Kindly provide your GST Number and
Pan Number

Your GST Number

Your PAN Number

CHECK THE CHECK BOX TO PAY ONLINE


Select the Check Box Given Below, if you wish to make payment
through secure online payment gateway - DEBIT / CREDIT CARD

Online payment

Online payment

Submit

Please do not click on Submit button twice.

Once you click on submit button, wait for the


payment page to appear in ‘New Tab’. Clicking
submit button multiple times may lead to multi-
ple transactions.
Payment Details

Life Time Membership Charges =


Rs. 11,800/- (10,000 + 18% GST)
Additional 200 Rs. applicable, if paying on-
line in lieu of bank charges.
Applicants are requested to make Demand
Draft / RTGS Transfer as per the details given
below :
Name of the bank A/C: ASI LIFE MEMBER-
SHIP AC
A/C no: 06780100001648
Type of account: SB Account
Bank name: Bank of Baroda
Branch name:Triplicane
Branch Address of the Bank: Bank of Baro-
da, 280, Triplicane Branch, Chennai – 600 005
———
SWIFT / IFSC code: BARB0TIRUVA
MICR code / Branch code: 600012017

Association of Surgeons of India GST De-


tails

GST Number 33AAATT1233G1ZY

Payment Through QR Code

GST Certificate :

For GST related query kindly contact on be-


low details :

Contact Person – Mr. S. Anandan


Email – [email protected]
Phone– 9840910775

Membership Benefits
ASI Golden Jubilee Award
ASI Ruby Jubilee Award
Benefits of Membership
Social Security Scheme of ASI

Photo Gallery
Photo Gallery 2015
Photo Gallery 2016
Photo Gallery 2017
Photo Gallery 2018
ASI Social Services Photo Gallery

HEAD OFFICE QUERIES


+91 44 25385584 [email protected]

ABOUT ASI
The Association of Surgeons of India was
established in 1938 to realise a long standing
wish among the Indian surgeons to get together
for the purpose of sharing each other’s
experiences and enhancing their surgical skills.
Starting from a humble beginning with a

Read more

MEMBER’S BENEFITS
Member Login
Membership Benefits
Apply ASI Fellowship
Apply ASI Membership
Social Security Scheme of ASI
Subscribe IJS Print Version
Professional Protection Scheme

PHOTO GALLERY
Photo Gallery 2023
Photo Gallery 2020
Photo Gallery 2019
Photo Gallery 2018
Photo Gallery 2017
Photo Gallery 2016
ASI Social Services

WEBSITE VISITS

ASI | ALL RIGHTS RESERVED


! "
POWERED BY WWW.CHILLITRENDS.COM

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