THE COCHLEAR IMPLANT GROUP OF INDIA

(Registered under the Karnataka Societies Registration Act 1960, Reg. No 728/2003-2004)

President: Dr. Sunil Narayan Dutt (Bangalore) Secretary: Ms. Nishita Mohandas (Mumbai)

Immediate Past President: Dr. Rajesh Vishwakarma (Ahmedabad)

Vice President: Mr. Ranjith Rajeswaran (Chennai) Jt. Secretary: Dr. Mohnish Grover (Jaipur) Treasurer: Dr. Ganji Srinivas (Hyderabad)

Executive Council Members:

Ms. Rashmi Deshpande (Bangalore) Ms. Meenakshi Wadhera (New Delhi) Mr. Chandrakant Vishwakarma (Ahmedabad)
Dr. Saumitra Shah (Surat) Dr. Milind Navalakhe (Mumbai) Dr. Sumit Mrig (New Delhi)

CIGI LIFE-MEMBERSHIP APPLICATION FORM

Title: Dr/Mrs/Ms/Mr Date:
First Name:
Middle Name/Initial:
Surname:
Gender: M/F
Age: DOB:
Designation: ENT Surgeon/Audiologist/ASLP/Rehabilitation Specialist
Full Mailing Address:

Contact Telephone (one number only):

Email ID for Correspondence (one ID only):
Recommended by: (Two Life Members with Membership Numbers and Signatures)
1.
2.

Applicant’s Signature:

Make a Demand Draft/Multicity Cheque for INR 5900 (5000 plus 18% GST) (Five thousand
and nine hundred rupees only) favouring “The Cochlear Implant Group of India.” You can
also do a Bank Transfer at: ICICI Bank, Jayanagar Branch, Elephant Rock Road, Block III,
Jayanagar, Bangalore 560011 Account Number: 005301036537 RTGS/NEFT/IFS Code:
ICIC0000053

Details of DD/Cheque/Bank Transaction:

Attach photocopies of: 1. Degree/Diploma Certificates 2. MCI/NMC/RCI Registration

Send the duly filled Application Form to: Dr Ganji Srinivas, Treasurer, CIGI at: Email:
gsrinivas.audiologist@gmail.com Cell: 9848161302 Address: #214, Road Number 3 East,
Vasavi Colony, near Ashtalakshmi Temple, Kothapet, Dilsukhnagar, Hyderabad 500035

Address for Correspondence : Ms. Nishita Mohandas, Secretary, Cochlear Implant Group
of India, B/26 Greenfields, Kapad Bazar Road, Mahim, Mumbai-400016, India.
Email: nishitamohandas@gmail.com