Join UPAOI : The Uttar Pradesh Chapter of Association of Otolaryngologists of India

Uttar Pradesh Chapter - Association of Otolaryngologists of India

Download the membership form where you can find instructions on how to join as a life member. Become a member today and enjoy all the benefits

All Life Members receive UPAOI journal for free
Exclusive Whatsapp group for the UPAOI members only
Discounts for registration in UPAOICON and other associated events
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Application Form

UP-AOI Life Membership Form

Fill the form below and submit. Our team will review and confirm your membership.

UTTAR PRADESH CHAPTER — ASSOCIATION OF OTOLARYNGOLOGISTS OF INDIA (UP-AOI)

APPLICATION FORM FOR UP-AOI LIFE MEMBERSHIP

Reg. No.: BAR/10427/2021-2022

Personal Information

1 Name in Full *

2 Date of Birth *

5 Email Address *

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Address

3 Full Address *

City *

State *

Pin Code *

Contact Details

4 Mobile No. *

Telephone (with STD Code)

WhatsApp No. (For UPAOI Members Only Group)

Qualifications

6 Degree / Diploma Details

Degree	College / University	Year of Passing
MBBS
MS
DNB
DLO
Others

Professional Details

7 MCI / NMC Registration No. *

Registration Date

Registration State

8 Practice Limited To

Otolaryngology only With other branch of medicine

9 Present Hospital or College Attachment

10 Member of AOI (National)?

Yes No

Membership Fee & Payment

Life Membership Fee

Rs. 5,000 / including journal subscription

Account Name Uttar Pradesh Chapter of Association of Otolaryngologists

Account No.

41049843417

IFSC Code

SBIN0018515

Branch SBI (18515) Abhaypur, Mohammadpur, P.O. Bhojipura, Nainital Road, Bareilly – 243202

Declaration

15 I hereby declare that the particulars given above are correct and I assure that if at any time any statement given above is found to be incorrect, my membership, if granted, will be liable to be cancelled and the fee paid by me will be forfeited. I hereby undertake that I shall abide by the Rules and Regulations of the UPAOI.

Date *

Signature (Type Full Name as Signature) *

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