Application Form

(Online)
Dear Sir,
Kindly enroll me as Life member of the Indian Pharmacological Society.
I agree to abide by the rules of society.
Admission fee 250/-
Life membership fee 2350/- / $260(include admission fees 250 )
Ordinary member ship fee 400/- / $20(no online facilty available, submit print out of this form for ordinary member ship)


First Name:*
Middle Name: Last Name:
Name to Appear*
Qualifications:*
Photo:
photo
Designation
Official Address:*
Phone: Mobile:*
Fax: Email:*  
Home Address
Bank Details:* Professional Email:  
Proposers profile
Name
NO: Signature:
NO: Signature:
I have gone through the constitution and bye laws of the society and will abide by the same
1. Please send a demand draft in favour of Treasurer, "Indian Pharmacological Society" payable at Ahmedabad
Please send the following along with the application
   Membership form signed by you and proposer
   Demand draft in favor "Indian Pharmacological Society" payable at Ahmedabad
   Academic Certificate
   Reference number received by you
Dr Bhagirath K Patel, Finance Secretary
Shivrath COE in Clinical Research,
3rd Floor, Anand Complex,
Near Sola over bridge,
Near B V Patel PERD centre,
Thaltej
Ahmedabad-380054
Gujarat

Mobile:(079) 30120311
Email: ips.membership@gmail.com