INDIAN ASSOCIATION OF PHARMACEUTICAL

SCIENTISTS AND TECHNOLOGISTS

MEMBERSHIP FORM

(Please Fill in BLOCK Letters)

For Office use only

Date of receipt

Membership No.

1. Name of Applicant :__________________________________________________________________________________

2. Designation :________________________________________________________________________________________

3. Qualification :_______________________________________________________________________________________

4. Date of Birth :_______________________________________________________________________________________

5. Mailing Address :____________________________________________________________________________________

6. Town City :_____________________Pin Code :______________________State :_______________________________

7. STD code :_________________Tel (Off.) :_________________Res :___________________Fax :__________________

8. E-mail :____________________________________________________________________________________________

Type of Membership [ Kindly tick ( þ  ) the appropriate box ]

Ordinary :                                               Life : 

Select three discussion groups (Maximum three) you want to be a part from the list below

(  ) Oral liquid preparation    (  ) Semisolid dosage form    (  )  Sterile product    (  ) Biological products    (  ) Biotechnological

Products    (  ) GMP Update and ISO certificate group    (  ) Drug rules and regulation    (  ) Pharmacology and therapeutics   

(  ) Medical Microbiology group  (  ) Applied Biochemistry group   (  ) Pharmaceutical Engineering and Technology group   

(  ) Community Pharmacy group    (  ) Clinical Pharmacy group    (  ) Biopharmaceutics group    (  ) Pharmaceutical and

medicinal chemistry group    (  ) Pharmacognosy and phytomedicine group    (  ) product development group    (  ) Patent

awareness and guidance group

Mode of payment [ Kindly tick ( þ ) the appropriate box ]

Cash :                                               Cheque :                                               Draft : 

Details of payment

I am hereby remitting Rs.___________________(in words Rs.____________________________________________ )

Through Cash / Cheque no.____________________/ DD no._____________________dated____________________

payable at Kolkata.

(Signature)                                                 

Membership Subscription

Ordinary member: Admission fees Rs.200/- or US $ 10 and amount subscription Rs. 250/- or US $ 25

Life member: Admission fees Rs.200/- or US $ 10 and Life time subscription Rs. 1400/- or US $ 50

Amount should be payable by crossed cheque or demand draft to: Indian Association of Pharmaceutical

Scientists and Technologists, payable at Kolkata. For out station cheque Rs. 50.00 should be added.

This is a computerised printable form, should be printed, completed and posted to the above address.