VENUE: May Fair Lagoon Hotel and Convention Center, Bhubaneshwar,Odisha.


MAYFAIR Convention is a 3-Star luxury hotel in Bhubaneswar offers the ambience wherein corporate events, business meetings and various formal and informal gatherings are held in a memorable and successful way.
MAYFAIR Convention is situated right opposite to MAYFAIR Group’s flagship property, MAYFAIR Lagoon. Jaydev Vihar, Bhubaneswar – 751 013, Odisha, India
Phone: +91 674 236 0111 Fax: +91 674 236 0136 Email: convention@mayfairhotels.com

All India Conference of GOSI

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LIFE MEMBERSHIP FORM GERIATRIC ORTHOPEDIC SOCIETY OF INDIA
Dear Sir,
I wish to apply for the LIFE MEMBERSHIP OF Geriatric Orthopedic Society Of India

1)Name(In Block Letters):--------------------------------------------
2)Age :--------------
3)Qualification and Year of Passing:--------------------------
4)Type of practice Goverment/Private/Institutions :---------------------------------------
5)Permanent Address
:---------------------------------------------------------------------------------------
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6)Phone Number :Land Line:----------------------------- Mobile:-------------------------
7)Email Id :---------------------------------------------------

Proposed By:

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Signature

GOSI Life Membership Number: ..............

Seconded By:

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Signature
GOSI Life Membership Number: ..............

Please fill the Membership application and make a Demand draft/Cheque of Rs.3000/- (Rupees Three Thousand only) in favor of “Geriatric Orthopedic Society of India (GOSI)” payable at Bangalore and send it to the below mentioned address along with:Certified copy of the PG degree/diplomaCertified copy of the Medical Council Registration

Direct NEFT - Transfers may also be made to the following account:
Account Name: GOS
Bank: Andhra Bank
Branch: Bilekahalli, Bannerghatta Road
Account No: 119610100003730
IFSC Code: ANDB 000 1196

Dr John Ebnezar,
Founder President
Geriatric Orthopedic Society Of India
Working Office: Parimala Health Care Services, Bilekahalli, Bannerghatta Road,
Bangalore –560076. Karnataka, India
Phone: 080 - 26581231


FOR OFFICE USE ONLY:
Date of receipt of the application:
Registration Number:
Authorized signatory