Registration Form
Name
S/D/W/o
Date of Birth
Date
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31
Month
01
02
03
04
05
06
07
08
09
10
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Qualifications
Registration No.
Sub Speciality (if any)
Contact details
Clinic/Hospital/Practice Address
Phone
Residence Address
Phone
Correspondence Address
Phone
Email
Fax
Proposed by
Dr.
Membership No.
Seconded by
Dr.
Membership No.
[Must submit a copy of the MBBS / MD / DO & State Medical Council / MCI Certificate for our records]
I agree to become a life member of the Delhi Ophthalmological Society and shall abide by the Rules and Regulations of the Society.