The Kolkata Association of Ophthalmologists

KAO MEMBERSHIP FORM

Please complete all the sections below

Fields (*) are mandatory

Prefix: *

First Name: *

Middle Name:

Last Name: *

Date of Birth: *

(Date & Month only, not year)

Contact Information:

Mobile: *

WhatsApp No.

Preferred Email ID: *

2^nd Email ID:

Home No (or Others No.):

Best Time to Call

Address Information:

Present Address: *

PIN: *

Permanent Address:

PIN:

Office Address:

PIN:

Qualification:

Medical Registration No.: *

WBMC / Other: *

MBBS DETAILS:

MBBS Completion Year:

University & City:

DO / DOMS DETAILS:

DO / DOMS Completion Year:

University & City:

MS / MD DETAILS:

MS / MD Completion Year:

University & City:

OTHER DETAILS:

Completion Year:

Others University & City:

Professional Information:

Organisation: *

Job Title: *

Sub- Specialty: *

Membership Fee - Rs. 3000, payable by Cash/ Cheque/ Draft/ Online Net Banking.
Cheques payable to The Kolkata Association of Ophthalmologists
Outstation cheques are not accepted.
Please drop payments to The KAO Secretariat, 2/5, Sarat Bose Road, Sukhsagar, Kolkata- 700 020
Account Details for Net Banking Payments - Please E-mail(Ophthalmologykolkata@gmail.com) with a screenshot of the Transaction & the exact time of the online payment. or Enter detail information through your account login.

Account Name: The Kolkata Association of Ophthalmologists
Account No: 6918460179
Bank Name: Indian Bank
Branch: Sarat Bose Road,
Kolkata - 700020
IFSC Code - IDIB000S040