APPLICATION FOR ASSOCIATE MEMBER ONCOLOGICAL SOCIETY OF BENGAL ONLINE APPLICATION CHARGE BREAK-UP ASSOCIATE MEMBER APPLICATION FEES : ₹ 2,500 + Payment gateway chargePAYMENT GATEWAY CHARGE : ₹ 61.00TOTAL : ₹ 2,561 ASSOCIATE MEMBER APPLICATION FORM Please fill up all the details carefully. Upon successful submission you will be redirected to our payment gateway. Surname (required) Name (required) Date of Birth (required) Sex (required) MaleFemale Nationality (required) Present Designation (required) Medical Registration No (required) Hospital / Office Address (required) Permanent Address (required) Mobile No (required) Phone No Email Id (required) Fax No Discipline (required) RadiotherapySurgical OncologyMedical OncologyHemato-oncologyRadiologyOncopathologyPalliative careOther You are applying for Associate Member ( Please attach a separate sheet, if reqd. Max filesize: 5MB) Please upload your passport size photo (Max: 2MB) (please upload only jpg, png or gif) I hereby declare that the details furnished above are true and correct to the best of my knowledge and belief and I undertake to inform you of any changes therein, immediately.