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THE IMMUNO-ONCOLOGY SOCEITY OF INDIA MEMBERSHIP FORM Office Address: 1115, Homi Bhabha Building, Tata Memorial Hospital, Dr. Ernest Borges Road, Parel, Mumbai - 400 012 Contact Number: Ms. Suvarna Damanapally : 9082527211 Email: [email protected], [email protected] Title: Prof. Dr. Mr. Mrs. Ms. First Name: Last Name: Speciality: Department: Hospital Name: Mobile No: Email: (All Correspondence will be by e-mail) Postal Address: City: State: Kindly transfer membership fee of Rs. 5000/- by NEFT I-OSI Bank Details Name: IMMUNO ONCOLOGY SOCIETY OF INDIA Account Number: 50100264162731 Bank: HDFC Branch: Shapoorji Pallonji Building, Dr Shirodkar Marg, Near KEM Hospital, Opp Bata Showroom, Mumbai-400012, Maharashtra IFS Code: HDFC0000357 Once you transfer membership fee kindly email us filled membership form with tranfer details on [email protected] Date of Transfer: NEFT Transaction ID: Signature: Date: FOR OFFICE USE ONLY Enrolled as Life / Associate / Honorary / Corporate / NGO Membaer of Immuno-Oncology Society of India Name: Folio No: Receipt No: Dated: Authorised Signatory
