THE KANDY SOCIETY OF MEDICINE

KSM Office, General Hospital, Kandy

Tel : 08-2201702 / Fax: 081-2233336
Email: theksm@slt.lk

APPLICATION FOR LIFE MEMBERSHIP

LAST NAME : .....................................................................................................................

OTHER NAMES :......................................................................................................................

DATE OF BIRTH :......................................................................................................................

BASIC UNIVERSITY DEGREE :..............................................YEAR ............................................................

YOUR CURRENT SPECIALTY :......................................................................................................................

SCIENTIFIC PUBLICATIONS :......................................................................................................................

(Please attach a list of publications)

PERMANENT ADDRESS :......................................................................................................................

CONTACT ADDRESS :......................................................................................................................

TELEPHONE (Res. & Mobile) : .....................................................................................................................

EMAIL : .....................................................................................................................

SIGNATURE :..............................................DATE ............................................................

Two present members who introduce you to the society.

Name Signature

……………………………………………….. …………………………………………

………………………………………………. …………………………………………

Please attache a photocopy of the SLMC Reg. Certificate.

(Life membership fee is Rs. 1500 / Cheque to be drawn in favour of the ‘Kandy Society of Medicine’)

CASH:……………………........................................ CHEQUE: ……….…………………………………….

Approval for membership

………………….. ……………………
President – KSM Jt. Secretary – KSM