Register – AOI West Bengal

Become a member of AOI West Bengal

Title
Dr.

First Name

Middle Name

Last Name

Date of Birth

Email Id

Mobile No

Permanent Address

Address

District

Pin Code

City

State

Mailing Address

Mailing address same as permanent address.

Address

District

Pin Code

City

State

Medical Council Registration No

Medical Council Registration Certificate:

(Updated Medical Council Registration Certificate: in pdf format and file size should not be more than 100 KB)

Registration Date:

Medical Council:

Upload Your Profile Picture

(Recent Photo: with good contrasting background and clearly visible face from front, not covered with mask/ goggles/ cloth. The picture should be in jpg format and size should not be more than 100 KB)

Upload Your Signature

(The size should not be more than 100 KB)

Whether member of any other professional body Yes No Add More

Present Hospital or Institution attachment if any Yes NoAdd More

QualificationAdd More

Degree	Year of passing	College	University	Upload Certificate (Certificate in pdf format and file size should not be more than 100 KB)
MBBS*
MS
DLO

Reference

(Give reference of two AOIWB Members who knows you personally)

Name:

AOIWB LM Number:

Name:

AOIWB LM Number:

I wish to join the A.O.I.W.B. as:

(Admission Fees: Rs.200/- for all.)

Life Membership
[ Registered Medical Graduates with a post graduate qualification in Otolaryngology and practice limited to Otolaryngology. ]

Associate Membership
[ Registered Medical Graduates doing Post Graduation in Otolaryngology and Head-Neck Surgery ]

Member Type	Registration Fee
Life Member	Rs 4000/-
Associate Member	Rs. 200/- Yearly

#Total payable: 4410.00
#Your fee: 4000.00
#Admission Fees: 200.00
#Internet Handling Charges: 210.00

I agree to abide by the Rules and Regulations of A.O.I.W.B.

(N.B. : Associate Member will not be eligible for voting right or to hold office of the Association)

Office :

CMCHouse, 91B,CRAvenue, Kolkata, 700073,West Bengal
Phone : 033 22258548, 033 22219738,
Mobile : 9831047663
Email : info@aoiwb.com
Website : www.aoiwb.com