DELHI CHAPTER INDIAN ASSOCIATION OF PATHLOGISTS & MICROBIOLOGISTS

APPLICATION FORM

1. Name : 2. Address(Res.) : Address(Off.) : Telephone(Res.) : 3. Email : Date of Birth : 4. Academic Qualification Degree/Diploma Year University/Institution (Off.) : Gender : Age : (Yrs.)

5. Present Designation/Occupation : 6. Special Interest : 7. Zone No. :

(SIGNATURE OF HOD) NOTE : SUBSCRIPTION : Resident's Application to be forwarded by the respective HOD

(SIGNATURE)

Rs 800/- Life Membership payable by Cash/DD in the Name of Delhi Chapter IAPM

Please give your address for correspondence so that circulars can be sent regularly at a permanent address in case of change in job. FOR OFFICE USE ONLY Received Receipt No. Membership No. Life / Ordinary Amount

(SECRETARY)

(TREASURER)