IAP Chapter on Growth, Development&Behavioural Pediatrics

Membership : IAP GDBP

Application Form For Life Membership

To
The Secretary
IAP Chapter on Growth and Developmentand Behavioral Pediatrics
Dr Jaydeb Ray
98 Ballygunge Place, Kolkata - 700 019
Phone : 033-24605172
Mobile : 09831054552

Dear Sir,

I wish to enrole myself as a Life Member of IAP Chapter on Growth and Development. The details are given below :

1. Name :Surname Firstname Middlename
(use Block Letter)

2. Male Female

3. Central IAP Membership No. :

4. IAP Non Member (Phychiatrist/Phychologist/Counsellor/Teacher) :

5. Corresponding Address :

6. Designation in Institute (If any) :

7. Academic Qualification(s) :

8. Phone No. (R) :

Office/Chamber :

9. Fax No. :

10. Email :

11. Date of Birth :

12. Bank Draft/Cheque No. Name of Bank

Branch Amount

Cash

Date :

Signature :

Fife Membership Fee : Rs. 550
Cheque/DD to be drawn in favour of
"IAP Chapter on Growth and Development"
payable at Kolkata Personal Communication

Dr S N Parida
Chairperson, IAP Chapter on Growth, Development and Behavioral Pediatrics

Dr Jaydeb Ray
Secretary, IAP Chapter on Growth, Development and Behavioral Pediatrics
98 Ballygunge Place, Kolkata - 700 019
Phone : 033-24605172
Mobile : 09831054552
Email : jaydeb_ray@hotmail.com