Membership Application Form Download From

First Name Middle Name Last Name
Age Sex Date of Birth
Address(Res.)
state
city
Pin
Tel
Fax
Mobile
Address(Clinic/ Office.)
state
city
Pin
Tel
Fax
Email
Institution/ Hospital Affiliations (Teaching/ Non teaching)
Title
Qualifications and year of acquiring it
Preferred Address for Correspondence : Home Office/Clinic
Life Membership fee of Rs. 5000/- to be sent by cheque or demand draft in favor of ISMPO. Foreign Membership fee is USD $ 100, include subscription to Indian Journal of Medical & Pediatric Oncology.
Member fees are enclosed as cheque (Account payee only) or a demand draft (including Rs. 25/- processing fee).In the favor of ISMPO and payable at Mumbai.
Number Date
Drawn on for Rs.
In addition I agree to comply with/ support the following:
1. ISMPO constitution and byelaws
2. Continuation of membership will require my ongoing commitment and active contribution to the activities of ISMPO
Signature Date Place
Proposed by Seconded by
Date Date