DIABETIC FOOT SOCIETY OF INDIA

APPLICATION FOR MEMBERSHIP

Medical and Paramedical professionals practicing allopathic or other type of medicine, or any person interested in Diabetic Foot can become a member. See below. Fill all the details fully.

Attachments- Medical Council Registration and Degree Certificate for Doctors

Nursing Council Registration for Nurses

For all others interested there educational qualification certificate

TITLE Dr / Mr / Ms / NAME IN CAPITALS:
M ÿ F ÿ / DATE OF BIRTH:

PRESENT DESIGNATION

/

HOSPITAL / CLINIC ADDRESS

STATE

/

PIN CODE

RESIDENTIAL ADDRESS

STATE

/ PIN CODE
TELEPHONE with national and Local STD code / HOME ( ) / BUSINESS ( )
FACSIMILE / HOME ( ) / BUSINESS ( )
E-MAIL ADDRESS
MEDICAL REGISTRATION NO.
DATE AND PLACE OF ISSUE

TERTIARY / HIGHER EDUCATION STUDIES

INSTITUTION NAME / QUALIFICATION
(Bachelor’s degree/Postgraduate course)

Reasons for joining DFSI

1.  We do diabetic foot work, hence desire to be a part of DFSI

2.  Want to learn more about Diabetic Foot

3.  As part of Conference Organizing Committee

4.  Any other –

Memberships of other professional organizations (if any)

Honours and Awards if any

Note: If you are a person trained in Allopathic Medicine you are required to pay Rs 5000/- for the life membership which is the only option for allopaths. All others are associate members and will pay only Rs 1500/- for their life membership. This distinction is on account of the associated members NOT having any voting rights which the Allopaths have. Nor can the new associate members have the right to run for the Executive Committee posts. Tick as applicable.

A Life Member Rs 5000/- Life Membership is the only memberaship option.

A Life Member Rs 1500/- Life Membership for non allpathic persons

Signature / Date

Membership dues may be sent as a Cheque / DD drawn in favour of “DIABETIC FOOT SOCIETY OF INDIA”. For all outstation cheques within India add Rs.50/- as bank service charges, unless it is payable at par at all branches. DDs should be payable at New Delhi. The payment should be sent with other hard copies to

1.  Dr Ashok Damir, Treasurer, Diabetic Foot Society of India, Director, Delhi Diabetes Centre & Foot Care Research Centre,U-29, West Patel Nagar, N.Delhi-110008, Ph: 011-25871666, +91-9810262600 E-mail:

AND the scanned copies of the same to

2.  Dr Rajesh Kesavan, Secretary, Diabetic Foot Society of India, Hycare for Wounds, Aysha Hospital, No.91-A, Millers Road, Kilpauk, Chennai-600 010, Ph: 9360778800

E- mail: and

3.  An Electronic Copy to Dr Arun Bal, President, Diabetic Foot Society of India at .

This will facilitate screening of the application, any unfilled requirements may be pointed out immediately and corrected. This will help the President, Secretary and Treasurer to approve application provisionally till it is ratified by the Executive committee.

Encl: Cheque / DD No. ………..…………………………………… dated …………………………………..

Drawn on (branch and Bank name) …………………………………………………………………………………………………..

For Rs. …………………………, … Rs. in words) ……………………......

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