Life Membership Form

Life Membership Form
Name

PrefixFirst NameLast Name
Highest Qualification
Designation
Hospital Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Email
example@example.com
Phone Number
Please enter a valid phone number.
Signature

Clear
Life Membership Fees: Rs. 5000/- (Rupees five thousand only)Payment by Cash/ Cheque/ Demand Draft in favour of AOGIN-India, payable at New Delhi. (Please addRs. 30/- for outstation cheques)
Cheque No/Transaction Id
Dated

DayMonthYear
Date
For the sum of
NEFT DETAILS: SBI bank Account holder name- AOGIN India, A/c no. 30465776898, IFSC code-SBIN0001536, SBI Ansari Nagar New Delhi-110029.
Should be Empty:

Life Membership Fees: Rs. 5000/- (Rupees five thousand only)Payment by Cash/ Cheque/ Demand Draft in favour of AOGIN-India, payable at New Delhi. (Please addRs. 30/- for outstation cheques)