Society of Transplant Imaging and Intervention, India

Membership Form

Personal Details

Title *

First Name *
Middle Name
Last Name *
Email *
Country Code *

Mobile *
Gender *
Date of birth *
Age

Mailing Address *
Country
State *
City *
Postal Code *

Permanent Address
Country *
State *
City *
Postal Code *

Professional Details

Current Designation *
Affiliated Hospital Name *
Affiliated Hospital Address *
State *
Medical Council Number *
Speciality *

Registration Fee

Life Membership	5000
Associate Membership	5000
Student Membership	Free
Trade Membership	25000

Mode of Payment

Online Payment

Wire Transfer

Cheque-Draft

Wire Transfer RTGS / Acknowledgement No
Transfer Date

Bank Details (For NEFT/RTGS payment)

Account Name	Society of Transplant Imaging and Intervention
Account No	7431789243
Bank Name	INDIAN BANK
Branch Name	KMCH GOLDWINS BRANCH
IFSC Code	IDIBOOOK169