Full Membership Associate Membership Industry / Corporate Member
           
Honorary Fellow Fellowship    
           

IMPORTANT NOTICE

Application will not be considered unless all sections are complete and all supporting documentation has been received by the Executive Committee.

I. GENERAL INFORMATION

FULL NAME



OFFICE ADDRESS

HOME ADDRESS

OFFICE HOME
       

II .EDUCATION

UNDERGRADUATE:



OTHER GRADUATION:



MEDICAL SCHOOLING:



III. PROFESSIONAL TRAINING

1. TYPE

2. TYPE

1a. SPECIALITY

2b. SPECIALITY

IV. FELLOWSHIP IN CARDIAC & VASCULAR INTERVENTIONS / SURGERY

3a. SPECIALITY

3b. PERCENT OF TIME SPENT

V. CERTIFICATE OF ADDED QUALIFICATION (not required for fellowship)



VI. CURRENT MEDICAL LICENSURE

1.



2.



VII. CURRENT AND PAST PRACTICE ACTIVITIES

1.

















2. PERCENT OF TIME SPENT

VIII. PROFESSIONAL SOCIETIES

1.













YES NO
       
YES NO
       
YES NO
       
YES NO
       
YES NO
       
YES NO
       
YES NO
       
YES NO
       

IX. OTHER QUALIFICATIONS

X. SPONSERSHIP

FELLOWS ARE NOMINATED FROM THE ACTIVE MEMBERSHIP OF THE SOCIETY AND MUST BE IN GOOD STANDING IN THE SOCIETY FOR AT LEAST THREE YEARS. (IN EXCEPTIONAL CASES THEY MAY BE DIRECTLY NOMINATED)

LETTERS OF RECOMMENDATION ARE REQUIREDFROM TWO APVS FELLOWS IN GOOD STANDING (USE ATTACHED FORMS)


APPLICANT FULFILLS WHICH OF THE THREE CRITERIA:

UTHOR OF AT LEAST FIVE (5) SGNIFICANT PAPERS
   
S A PROGRAMME DIRECTOR OR CATH LAB DIRECTOR/ VASCULAR SURGERY
   
AS BEEN INVOLVED IN SUPERVISION/TRAINING OF RESIDENTS/FELLOWS
   
CANDIDATE HAS BEEN AN EXCEPTIONAL LEADER
   










MAKE SURE THAT YOU HAVE INCLUDED THE FOLLWING WITH YOUR MEMBERSHIP FORM:

CURRICULAM VITAE
(300-400 Words)
PHOTOCOPY OF YOUR POST
GRADUATE/SUPERSPECIALTY CERTIFICATES
       

MEMBERSHIP FEES

Category
Yearly Membership
Life Membership
USD
INR
USD
INR
Honorary Member
- - - -
Associate Member
$ 50 1,000/- $ 100 3,000/-
Full Member
$ 100 3,000/- $ 300 10,000/-
Fellowship
$ 150 3,000/- $ 300 10,000/-
Industry / Corporate Member
$ 200 5,000/- $ 500 20,000/-


PAYMENT

Pay Online by Credit Card / Debit Card / Net Banking

Pay offline by Cash / Cheque / Demand Draft / NEFT / RTGS

Axis Bank
Acc. No.: 911010028201409
IFS Code: UTIB0001148

Please make Demand Draft in favour of “Asia Pacific Vascular Society”, payable at New Delhi



MAIL YOUR FORM TO:

Dr. (Prof.) N. N. Khanna

MD, DM, FRCP (Lond.), FRCP (Glasg.), FRCP (Edin.), FACC (USA), FSCAI (USA), FESC, FCSI, FICC

Organising Chairman & Secretary, APVIC – VIII

Sr. Consultant Interventional Cardiology & Vascular Interventions Coordinator - Vascular Services

Advisor - Apollo Group of Hospitals Indraprastha Apollo Hospital Delhi - Mathura Road, Sarita Vihar, New Delhi – 110076

RSVP: Dr. Monica Kher : +91-9958244778

Shillpa Mahajan 011-29871751 (12 pm - 6 pm Monday to Saturday)

Conference Secretariat mobile : +91-8447310885, 011-29871899
E-mail : contact@apvs.in, www.apvic.com, www.apvs.in