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

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