Intraocular Implant and Refractive Society, India Membership Application Form
Membership fee Rs 2000

A/C NAME: INTRAOCULAR IMPLANT & REFRACTIVE SOCIETY, INDIA

 CURRENT A/C NO. 10712739324
 IFSC CODE: SBIN0000962

BANK DETAILS
STATE BANK OF INDIA
320 AVVAI SHANMUGAM SALAI
GOPALAPRAM BRANCH
CHENNAI-600086, INDIA
BANK CODE NO:0962

CHEQUE/ DD TO BE PAYABLE IN FAVOUR OF "INTRAOCULAR IMPLANT & REFRACTIVE SOCIETY, INDIA"

First and Last Name *
(Please furnish first name under which you wish to be registered)
Your answer
Email Adress *
Your answer
Mobile Number *
Your answer
Mention The Alphabet under which you wish your name to be indexed *
(Example for Joseph Dean its "J")
Your answer
Date of Birth *
MM
/
DD
/
YYYY
Address for Communication *
Your answer
City *
Your answer
State *
Your answer
Pin Code *
Your answer
Present Status *
Your answer
Qualification (s), University and Year
Your answer
Qualification (s), University and Year
Your answer
Qualification (s), University and Year
Your answer
Registration No. & State in which registered *
Your answer
Proposed by
Name and IIRSI Membership Number
Your answer
Seconded By
Name and IIRSI Membership Number
Your answer
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