Membership Form

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Association of child neurology membership form 

Full Name
Gender
MaleFemale
Current designation
Full address with PIN CODE
Mobile number
Email address
Landline alternate number (if any)
Educational qualifications
Have you finished your training in pediatric
neurology
YesNo
Place of training in pediatric neurology and
duration of course
AOCN Member who proposes your membership along with his membership
Number Email Id
Clinical experience in pediatric neurology
Online transaction ID (date)
Category A 5000 Rupees /
Category B 4000 Rupees
Category of membership applied (Category
A/B)

Signature of Applicant
I declare that all the above information are true to the best of my knowledge