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To,
The Honorary Secretary
The Association of Surgeons of India
21, Swamy Sivananda Salai,
Chepauk, Chennai- 600 005
Affix Self Attested
Ph: 044-25383459, 25381685 , Fax : 044- 25367095
Photograph
Step 1: Applicant Information (in Block Letters)
First Name:
Middle Name:
Last Name:
Sex:
Blood Group:
Qualification:
Email:
Institution:
Title/Department:
Mailing Address
City:
District:
State :
Pin Code:
Country:
Mobile Number:
Landline Number:
STD Code Number
Fax:
Residential Address:
City:
District:
State:
Pin Code:
Country:
Mobile Number:
Landline Number:
STD Code Number
Fax:
STD Code Number
Step 4: Education
Institution Degree Awarded Date (DD/MM/YY)
College/University: / /
Medical School: / /
Postgraduate Training: / /
.
Step 7: Area of Specialization
Breast
Colorectal
Education
Endocrine
Gastrointestinal
Genitourinary
Hepatobiliary
Laparoscopic
Oncosurgery
Pediatric
Thoracic
Vascular
Step 8: Academic (teaching) Experience, if any
Step 9: Research
Please begin with the most current.
Publications
I hereby declare that the particulars given above are correct and I am aware that if at anytime, any
statement given above is found to be incorrect, my membership, if granted, will be liable to be cancelled
and the fee paid by me will be forfeited.
I hereby undertake that I shall abide by the rules and Regulations of the Association of Surgeons of
India.
Name:
Place:
Signature
SPONSORSHIP
Sponsored by 1. Dr:
Signature
2. Dr:
Signature