Society of Minimally Invasive Cardiovascular and Thoracic Surgeons of India (SMICTSI) REGD. NO.S-E/1044/Distt. South East/2016 MEMBERSHIP REGISTRATION FORM
Please fill legibly in BLOCK letters       Upload your photograph  (Photograph size less then 2 MB) 1. Name (in full) *Required Field 2. Qualification   *Required Field 3. Speciality   *Required Field 4 Designation 5 Date of birth *Required Field 6 Gender Male Female 7. 1. Address 1 (Official) (Institution/Hospital/Clinic) *Required Field a. Mobile (with code)   *Required Field b. Landline Phone (with code) c. Email ID   *Required Field 2. Address 2 (Residence/alternate   a. Mobile (with code) b. Landline Phone (with code) c. Email ID 8. Medical council registration number 9. Place of registration 10. Basic Degree (MBBS) a. Year of joining b. Year of passing c. College/Institution d. Degree awarded by 11. Degree (General Surgery) a. Year of joining b. Year of passing c. College/Institution d. Degree awarded by 12. Degree (Cardiovascular and Thoracic Surgery) a. Year of joining b. Year of passing c. College/Institution d. Degree awarded by 13. Other (degrees/qualifications/research or work) a b c d 14. Membership Category Applied for    Life Member Life Member (by upgrade) Associate Member (cardiac) Associate Member (non-cardiac) Overseas Life Member (SAARC countries) Overseas Life Member Non-(SAARC countries) 15. Declaration (by applicant) I hereby accept to abide by the rules, regulations, and bylaws of the IACTS as per the constitution and as revised from time to time. 16. Membership payment details Mode of payment Amount Cheque/DD/Online receipt number Date a. Cash b. Cheque c. Demand Draft d. Online bank transfer 17. Membership fee details a. Life Member One-time fee of INR 12,000.00 b. Life Member (by upgrade) INR 5,000.00 (existing Associate Members only) c. Overseas Life Member (SAARC countries) One-time fee of INR 15,000.00 d. Overseas Life Member (Non-SAARC countries) USD 1000.00 e. Associate Member (cardiac) One-time fee of INR 8,000.00 f. Associate Member (non-cardiac) One-time fee of INR 8,000.00 18. a. Bank Details b. Cheque/DD Account Name: Society of Minimally Invasive Cardiovascular and Thoracic Surgeons of India Account Number: 36119022797 Bank Name: State Bank of India Branch: Escorts Heart Institute IFSC Code: SBIN0010448 Cheque or DD should be in favour of: “Society of Minimally Invasive Cardiovascular and Thoracic Surgeons of India”. Payable at New Delhi 19. Checklist a. Completed membership registration form with signature b. Cash, cheques, demand draft or online payment receipt c. Self-attested copy of MBBS degree certificate d. Self-attested copy of medical council registration e. Self-attested copy of MS/DNB degree certificate f. Self-attested copy of MCh/DNB degree certificate (if applicable) g. Self-attested copies of other educational certificated (if details provided for SI. No. 13) h. Letter from Head of Department (if applying for Associate Membership)