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Society of Chest Imaging and Interventions (SCII)

SOCIETY OF CHEST IMAGING AND INTERVENTION

Membership Application Form

Kindly fill in BLOCK LETTERS

Title

First Name

Last Name

Age

Date of Birth

Email

Gender

Male

Female

Phone

Qualifications

Department

Institute

Street Address

City

Postal / Zip code

Region/State/Province

Country

Street Address

City

Postal / Zip code

Region/State/Province

Country

Medical Council registration No.

Number of hours/ week spent in chest radiology

Name of council (MCI/state)

Membership of other professional society/body, if any

Membership Amount

Life member (Rs 5000)

Corporate member (Rs 5000)

Student Member (Rs 1000)

Honorary member

Corresponding member (Rs 10,000)

Mode of Payment

Cheque/Demand Draft

Bank Transfer

Online payment

Cheque/Demand Draft (in favour of ‘Society of Chest Imaging and Intervention’) Cheque/DD no. . . . . / Date . . . . . / Bank . . . . .

Bank Transfer: A/c Name : Society of Chest Imaging And Intervention, A/C No. : 3719071850, IFSC: CBIN0280631, Bank : Central Bank of India, S.V.P. Road branch, Mumbai-400004

Online payment ID

Please upload your passport size photograph

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Please upload your Qualification proof

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I agree to abide by the memorandum and by-laws of the society and by such rules and regulations as may be enacted from time to time.