PSS-Membership Form

Membership Form

Payment Details

Please pay Rs. 5000/- towards Life membership of the Poona Surgical Society.
The payment to be made by:

1. Demand draft /Cheque drawn in favour of “Poona Surgical Society” payable to Treasurer, PSS

Treasurer: Dr. Bharat Dikshit

2. Online fund transfer to:-

Account Name:- Poona Surgical Society
Bank name:- HDFC Bank
Branch name:- Aundh
Account no.:- 59200000022111
IFSC code:- HDFC0003981
Account Type: Current

Membership Form

Title*

First Name*

Middle Name

Last Name*

Date of Birth*

Upload Member Photo* (JPG / JPEG / PNG / PDF Upto 2 MB only)

Highest Qualification*

Upload Qualification Certificate* (JPG / JPEG / PNG / PDF Upto 2 MB only)

Specialty*

Medical Council Registration Number*

Address

Address Line 1*

City*

Postal Code*

State*

Country*

Upload Residence Proof* (JPG / JPEG / PNG / PDF Upto 2 MB only)

Mobile No.*

Alternate Mobile No.

Email Id*

Alternate Email Id.

Other Contact No.

Payment Details
Mode of Payment*

Cheque / DD

Online

Membership Form

Amount: Rs 5,000