Personal Information:
Last Name: |
First Name: |
| Middle name or initial: |
|
| Date of Birth: |
Sex (M/F): |
|
|
|
| Address: |
|
| Home Address:
|
|
| Office Address:
|
|
| Email: |
|
|
|
|
| Phone Numbers (Including Area Code): |
| Home: |
Office: |
|
|
| Present Position: |
|
| Name of Institution: |
|
| Position: |
|
|
|
|
| Academic Background:
(indicate
degrees/ diplomas, year from which it was obtained)
|
| Professional Category
(Please tick): |
| Physician (Indicate Specialty): |
Nurse: |
| Dietician / Nutritionist: |
Biochemist: |
| Pharmacist: |
Industry: |
| Pharmacologist: |
Others (Specify): |
|
|
| Signature:............................. |
Date:..................... |
|
Mail your filled in membership form with payment by cheque
favouring ISPEN to :
Dr. Sarath Gopalan
Secretary, ISPEN
Nutrition Foundation of India
C13, Qutab Industrial Area
New Delhi - 110016
Email: crnss@hotmail.com
|
|
Life Membership
Fee Physicians : Rs. 1500 Allied Medical/health Professionals - Rs.
750 Please add Rs. 30/- for all outstation cheques |