Membership : IAP GDBP
Application Form For Life Membership

To
The Secretary
IAP Chapter on Growth and Development
Dr. Sukanta Chatterjee

889A, Lake Town
Kolkata - 700 089
Tel : 2534 5909

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 Shabina Ahmed
Chairperson, IAP Chapter on Growth, Development and Behavioral Pediatrics
103 Suryya Apartments, 5 S K Bhuyan Road, Guwahati - 781 001
Dr Sukanta Chatterjee
Secretary, IAP Chapter on Growth, Development and Behavioral Pediatrics
889A, Lake Town
Kolkata - 700 089
R : 2534 5909; M : 98302 75685
Email : sukantachatterjee @hotmail.com

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