| Date
of Application |
|
| Name |
|
|
Address |
|
| City/State |
|
| Residence
Phone Number |
|
| Office
Phone Number |
|
| Mobile
Number |
|
| Email
ID |
|
| Educational
Qualification - (Degree / Diploma
Specialty University Year of Passing) |
| 1. UG (MBBS) |
|
| 2. Postgraduate (MD/Diploma/Fellowship/Membership)
|
|
| 3. Other qualification
(if any) |
|
| Areas of Special Interest |
| |
|
Institute |
|
Current Department
of Work |
|
| Payment Details |
| Amount |
|
DD/MO Number |
|
Dated |
(dd/mm/yyyy) |
(Payment should be made in
favor of Society for Emergency Medicine,
India, Payable at Hyderabad)
(Membership fee: - Rs. 1000 /-*)
*Additional transaction fee of Rs.50 applicable
for every Cheque |
| Attestation Statement |
| By submitting this application
using the "Submit" button below,
I testify that the information provided
in this application is true and accurate
to the best of my knowledge. I will provide
the organization, its Board of Directors
with any supporting documents requested
to support this information and these claims.
I understand that providing false information
may be considered grounds for dismissal
from SEMI. |
| ADDRESS
FOR COMMUNICATION |
HEAD
OFFICE ADRESS:-
Society for Emergency Medicine, India
Hyderguda, Hyderabad – 500029.
|
| |
| PRESIDENT’S
OFFICE ADRESS:- |
Dr.V.P.Chandrasekaran,
MD (A&E), D.A&E., Head, Dept.
of Accident, Emergency & Critical
Care Medicine,
Vinayaka Mission Hospital, Seeragapadi,
Salem,
Tamil Nadu – 636 308 |
|
|
|
