AOI Bihar Jharkhand Membership Form

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Account Details

ACC name : Mr. AOI BIHAR STAEE

Address : C/O S.N.BANERJEE , EYE DEPPT. P.M.C.H. PATNA-4

800012

Branch Address :Central bank of india , PATLIPUTRA PETH. , RAJENDRA NAGAR , PATNA

800016

ACC no. : 1352416126

IFSC code : CBIN0280011

Life Membership fees : Rs. 3000 ( Three Thousand Only )

Please e-mail a copy of your state medical registration certificate to aoibj25@gmail.com

Date *

YYYY

Title *

Professor

Doctor

Other:

Name *

Date of Birth *

YYYY

Highest Qualification *

DLO

Mch

MBBS ( and pursuing residency training in ENT)

Other:

Year of Passing

YYYY

Institute ( Qualification ) *

Residential Address *

Place Work

(Institute/Hospital/organisation)

Email *

Phone no. *

Proposed by (Name/LM number)

Seconded by (Name/LM number)

Payment QR given below

UPI id - 12357129@cbin

Payment Done

Payment details (Transaction Id /date ) *

Clear form

Never submit passwords through Google Forms.

This content is neither created nor endorsed by Google. - Terms of Service - Privacy Policy

Does this form look suspicious? Report