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APPLICATION FOR LIFE MEMBER

ONCOLOGICAL SOCIETY OF BENGAL

ONLINE APPLICATION CHARGE BREAK-UP

LIFE MEMBER APPLICATION FEES : ₹ 4000 + Payment gateway charge

PAYMENT GATEWAY CHARGE : ₹ 97.00

TOTAL : ₹ 4,097

LIFE MEMBER REGISTRATION 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

Fax No

Discipline
RadiotherapySurgical OncologyMedical OncologyHemato-oncologyRadiologyOncopathologyPalliative careOther

You are applying for
Life-Member

( Please attach a separate sheet, if reqd. Max filesize: 5MB)

Please upload your passport size photo (Max: 5MB) (please upload only jpg, jpeg, 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.

IMPORTANT LINKS

BENGAL CANCER SUMMIT 2023 REGISTRATION

PAYMENT PARTNER

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