asi sss 2014 application form - Association of Surgeons of India

FOR OFFICE USE ONLY
PHOTO
Of
Applicant
ASI Social Security Scheme 2014
The Association of Surgeons of India
21, Swamy Sivananda Salai,Chepauk,Chennai – 600 005
Ph: +91 44 25383459, 25385584 Fax: +91 44 25367095
Email: [email protected] Website: www.asiindia.org
APPLICATION FORM
(TO BE FILLED IN BLOCK LETTERS) ( PLEASE FILL THE FORM IN DUPLICATE)
File No.
ASI SSS No
Branch
State
Window period
ASI FL NO:
Name:
Name of Father/ Spouse:
Sex:
Age:
Date of Birth: (Attach Proof)
Qualifications:
PAN Card No
Name of State Branch of ASI:
Bank Details: Bank Name
A/c no
Branch
MICR No
IFSC CODE
Correspondence Address with State and Pin Code :
Tel. No
Mobile
Email:
DECLARATION BY THE APPLICANT
I, the undersigned hereby apply for the membership of ASI SOCIAL SECURITY SCHEME 2014. I am aware of
the rules and regulations of “The ASI Social Security Scheme 2014” and I will abide by it. I enclose herewith
Rs.
Demand Draft no
Dated
Drawn on
being the Admission Fees as per age along with Rs. 1500/-(before 31/12/14)/ Rs. 2500(after 31/12/14) as
Advance Fraternity Contribution. I also agree to pay the yearly Death Fraternity Contribution (DFC) demanded
as per no of death of members of this scheme from next year. I declare that information given by me is true.
Photo
Name of 1st Nominee
Photo
Name of 2nd Nominee
Of
Relationship to Applicant
Of
Relationship to Applicant
1st Nominee
Signature of 1st nominee
2nd Nominee
Signature of 2nd nominee
CERTIFICATE
To be recommended and signed by an Official of ASI
(Any Present Executive of State Chapter of ASI or State GC Member of ASI)
Name of The Official
State ASI Membership No
Signature
Copy of Application will be send to the State ASI President/Secretary
NOMINATED ASI SSS 2014 OFFICE BEARERS
CHAIRMAN
CO-CHAIRMAN
Dr CHIRANJEEV KHANDELWAL
Dr KAUSHIK SHAH
09431821878
09824044690
Applicant’s Signature
CO-CHAIRMAN
Dr SHALABH GUPTA
09811965686
Application Form with DD to be send in favor of ‘ASI SSS 2014’ payable at Chennai to
The Chairman, ASI SSS 2014, 21, Swamy Sivananda Salai, Chepauk, Chennai – 600 005, INDIA.
For Payment by NEFT Account Details are BANK OF BARODA, SB a/c No: 0678 01 000 13529
Branch: TRIPLICANE, IFSC code: BARB0TIRUVA (Please Quote the Transaction ID)

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