Membership - Thane Psychiatric Society

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Membership Application Form

Fill in the form below to apply for life membership of the Metro Psychiatric Society. Our secretariat will contact you once your application has been reviewed.

Please enter details in block letters where possible.

Personal Details

First Name *

Middle Name

Surname *

Date of Birth

Email ID *

Passport Size Photo

JPG or PNG, max 2 MB

Phone No. 1

Phone No. 2

Residence Address

Hospital / Clinic Address

Qualifications

Degree / Diploma / Fellowship	College / Institute / Hospital	University / Board	Year of Passing
MBBS
DPM
MD (Psy)
DNB (Psy)
Fellowship
MA / MSW
Ph.D.

MMC Reg. No.

IPS Life Membership / Fellowship No.

Life Member Fee Payment

Life Member Fees: Rs. 5000

Bank Name: THE KALYAN JANATA SAHAKARI BANK, KHADAKPADA BRANCH

Account Name: PSYCHIATRY SOCIETY OF THANE

Account No.: 012011100001070 (15 digits)

IFSC Code: KJSB0000012 (11 digits)

Email transaction screenshot to: Psychiatrysocietyofthane201@gmail.com

Payment Date

Transaction ID

Transaction Screenshot (optional)

Declaration

I do hereby declare that the above information is true. I solemnly affirm that I will uphold the aims and objects of the society and I have read and agree to abide by the constitution, rules and bylaws of the society.

Date

Applicant's Signature (type full name)