INDIAN ACADEMY OF ECHOCARDIOGRAPHY
NEW MEMBER APPLICATION FORM

 
:
 Life Member
 
:
 Associate Member
 
:
 Corporate Member

General Information ( Should be complete in all aspects )

Name
:
  
Date/ Year of birth
:
  
Address1
:
  
Address2
:
  
Address3
:
  
Clinic
:
 
Pin
:
  
Phone
:
    
Mobile
:
  
Email
:
  

API Membership Number
:
  
CSI Membership Number
:
  

Qualification
Degree
 University Year
Experience ( In Chronological order ) ( Attach Separate sheet if required )

Eligibility for Membership :

DM ( Cardiology ), DNB ( Cardiology ), MCH ( Cardiothoracic ), Postgraduate degree in cardiacanaestesia, MD ( Pediatric ) with one year active experience in echocardiography, MD/MRC.FRCP with two year training in echocardigraphy/Cardiology from a recognized centre, Certified echocardiography technicians as associate member.

Please send application with copies of medical degrees, certificates of experience signed by the relenvant authority.

How do you hear about IAE ?
:
 IAE Website
 
:
 Journal
 
:
 Mailing
 
:
 Conferences

Payment Mode :

Life Member
-
 
:
 Rs. 5,000/- or USD 500/- for physicians
 
:
 Rs. 4,000/- for technicians
Corporate M
-
 
:
 Rs. 50,000/-

Important Note :- Cheques/DD should be drawn in favor of " Indian Academy of Echocardiography " Payable at Delhi and also take print out of this form after submittion and attach it along with Cheques/DD and sent by Registered Post or Courier to the Secretary.

Date
:
 23/02/2012  
Signature
:
  

  Office Use Only :

Application received on
:
  
Recommendation from the crendential committee
:
  
Application received Back
:
  
Recommendation from the crendential committee
:
  
Accepted/ Rejected
:
  



 
Office USe Only
 
Member ID
:
  
Order ID
:
  



Signature of Secretary
Please Return to:

IAE INDIA HEAD QUARTER
C-1/16,ASHOK VIHAR, PHASE- II, DELHI - 110052 , INDIA
TELE/FAX: + 91-11-2741-9505, Mobile : 09311113246
E-mail: echoacadindia@yahoo.co.in