BREAST IMAGING SOCIETY (INDIA)

Registration No. S/1448/Distt. south/2013, New Delhi

Registered Office: Col Pants Imaging Centre, A-22, Green Park, New Delhi-110016
Tel: 011- 26855656 Email: breastimagingsociety@gmail.com www.bisi.co.in

MEMBERSHIP APPLICATION FORM

Name (CAPITAL LETTERS):

Date of Birth: Gender: Male Female

Mobile: Email:
Affix a passport size
Qualifications Year Institution
photograph
UG
PG
Other

Hospital/Clinic/Office Address:

City: State: PIN: Telephone (with STD code):

Facilities available:
Mammography Ultrasound MRI Wire localization
Stereotactic biopsy Ultrasound guided biopsy MR guided biopsy Vacuum assisted biopsy

Residential Address:

City: State: PIN: Telephone (with STD code):

Preferred address for correspondence: Hospital/Clinic Residential

Council registration No. Name of council (MCI/state):

Membership of other professional society/body, if any:

Membership requested: Life Member (for radiologist) Associate Member (for non-radiologist)

Membership proposed by (Life member of BISI)

Name: Membership number Signature of the proposer

Membership fee: 5900 Mode of Payment: Cheque or Bank Transfer

Cheque (in favour of BREAST IMAGING SOCIETY) Cheque no: Date: Bank:
Bank Transfer: A/c name: BREAST IMAGING SOCIETY, Bank of India, HauzKhas, New Delhi.
A/c no. 600510110004580 IFSC code: BKID0006005

FOR OFFICIAL USE OF BISI

Admitted as Life member / Associate member of Breast Imaging Society (India)

Membership Number: Receipt no: Signature of the General Secretary