Home
 
 
Membership Form
(Download Membership Form Word Format )
       
  All fields are mandatory  
       
  Name: (Block Letters)
The alphabet category you would lik to be coded under.
 
       
  Address(Permanent)  
 

For Communications:

  
  Proposed by  
  Pin Code:  
  Office Telephone:  
  Residence Telephone:  
  Date of Birth :  
  E-mail:  
  Category of Membership applied for: Associate/Full/Affiliate Degrees / Diplomas*  
  Dates When Obtained :  
  University/College:  
 

Present Appointment & Designation:

 
  Training in Urology:  
  Period of Training:  
  University/College/Hospital:  
 

Past Appointments:

 
 

Papers/Publication/Research Work Related to Urology and/or Allied Ancillary Sciences

 
  Details of membership in other Medical Associations:  
  ASI  
  IMA  
  Other (Specify)  
  For Change of Membership Category    
  Present Category:  
  Year of Joining USI:  
  Membership Number:  
  Reason for Change:  
 

Sponsors (Should be Full Members of the Urological Society of India)

 
  First Sponsor:    
  Name :  
  Address:  
  Address:  
  USI Number:  
  Second Sponsor:    
  Name:  
  Address:  
  Address :  
  USI Number:  
 

I declare that the information given above is correct and if elected, I agree to abide by the constitution of the Urological Society of India.

 
  Place:  
  Date :  
  Name  
   
 
For any other information please contact the secretariat at:
Dr. R M Meyyappan
No. 7, 3rd  Street, Kamraj Nagar
Sathya Gardens,  Saligramam
Chennai -600093 
Mob: 98400 68248
Ph:(Res)- 044-23643322
Email: menauro@gmail.com