Membership Form

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Surname

First Name

Middle Name

Date of Birth

Affiliation

Mailing Address

Phone no. (office)

Mobile

Professional qualifications:

Graduation: College/University

Year

Post Graduation: Degree & College/Univ

Year

Higher Degree/Fellowship/ Experience in IEM (if any):

Year

Highest Qualification Certificate

Recommeder's Name

Recommeder's Signature

Type of Membership requested (2017 onwards)

Ordinary member (2 years-Rs 2000) Corporate member (1 year- Rs 10,000) Associate member (2 year –Rs 2000) Life member (10 years- Rs 5000) Corporate member (life, 10 years- Rs 50,000) Overseas member (annual USD 25/life USD200)

Payment Details:

1. Demand Draft: in favor of “Indian Society of Inborn Errors of Metabolism” payable at Delhi.

Draft No.

Dated

Drawn on

2. Bank Transfer: Account / Beneficiary Name: Indian society of inborn errors of metabolism
Account no: 91111010000392

Bank Name: Canara Bank

IFS Code (RTGS/NEFT): CNRB0019111

Address: Sir Ganga Ram Hospital, Rajinder Nagar, New Delhi 110060

3. Cash payment:

Amount in Numbers

Amount in words

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