Association of Neuroscientists of Eastern India

Association of Neuroscientists of Eastern India

Membership Form

A. Name: ______

B. Date of birth: ______/______/______(DD/MM/YYYY)

C. Sex:

D. Affiliation: ______

E. Permanent Add: ______

______

F. Present Mailing Add: (if not same as permanent address):

______

______

G. Educational Qualification: (Degree and Institute)

a.Under graduate : ______

b.Post graduate:______

c.Post graduate in Sub- specialty:______

d.Any other:______

H. Neurosciences Training Institute: ______Years spent: ______

I. Are you a member of Neurological Society of India: Yes/No

If yes, please give your membership No. :______

J. Are you a member of Indian Academy of Neurology: Yes/No

If yes, please give your membership No. :______

K. This Application is for (Please mark Yes)

a)Life Full Member: _____

b)Life Associate Member: _____

c)Founder Member status: _____

1. email:______
2. Mobile No.:i) ______ii)______

N. Amount enclosed: Rs. ______By Cash/ Bank Draft/Cheque (No.______)

Bank:______

Signature:

Date:______

Proposed by:Seconded by:

Signature ______Signature______

Name: ______Name:______

Membership No.______Membership No.______

For Office Use only

Membership awarded under category: Life Full Member/Life Associate Member/Founder Member

Membership No. ______Subscription received: Rs______Any dues: Rs______

______

SecretaryTreasurer

Membership Fee

For Indians:Life Full Member: Rs. 2000/- in one installment

Associate Life Member: Rs. 1000/- in one installment

(When converting to Life Full member, Life Associate member will have to pay Rs. 1000/- only)

For Non Resident Indians

Full membership:$300.00 (or equivalent currency of the country of their residence)

Eligibility Criteria

Full membership

a)Persons with an MBBS of an India University recognized by the Medical Council of India or an Equivalent recognized degree of a Foreign University, in full time practice of any branch of neurological sciences after 3 years of training in a recognized Institution in one of the disciplines of neurological sciences.

OR

b)Those possessing graduate degrees or diplomas of a recognized university or Institution in any subspecialty of neurosciences

OR

c)Those possessing graduate degree or diploma such as M.D.,M.S., M.Ch., D.M., Ph.D., MRCP, FRCS, DNBor Diplomate of American or Canadian Board or an equivalent qualification of a recognized

University or institution followed by at least 2 years of training in any branch of neurosciencesat recognized neurological centre.

OR

d)Full members of the Neurological Society of India or the Indian Academy of Neurology, who have their origin or training or practice in Eastern India.

Associate membership

It shall be open to those doctors or scientists who show interest in any branch of neurological

Sciences through their professional or scientific activities, but don’t possess the eligible qualifications, necessary to become full members of the Association.

Founder membership

Full members of the Neurological Society of India or the Indian academy of Neurology shall beeligible to become founder members without any proposal if they apply within one year of the formation of the “Association “ along with admission and subscription fees for life full member

or full member.