Welcome to Asia Pacific Vascular Society

APPLICATION FOR (please check)*:

Full Membership	Associate Membership	Industry / Corporate Member

Honorary Fellow	Fellowship

UPLOAD YOUR PHOTO*:

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

LAST*:

FIRST*:

MIDDLE*:

D.O.B.*:

DESIGNATION (MD, DO, OTHER)*:

GENDER*:

OFFICE ADDRESS

HOSPITAL*:

WORKPHONE*:

WORKFAX*:

DEPARTMENT*:

E-MAIL*:

STREET*:

CITY*:

STATE*:

COUNTRY*:

ZIP CODE*:

HOME ADDRESS

HOME ADDRESS*:

STREET*:

CITY*:

STATE*:

COUNTRY*:

ZIP CODE*:

MAIL TO BE SENT TO (Check One)*:

	OFFICE		HOME

II .EDUCATION

UNDERGRADUATE:

SCHOOL*:

CITY*:

STATE*:

COUNTRY*:

GRAD. DATE*:

DEGREE*:

OTHER GRADUATION:

SCHOOL*:

CITY*:

STATE*:

COUNTRY*:

GRAD. DATE*:

DEGREE*:

MEDICAL SCHOOLING:

SCHOOL*:

CITY*:

STATE*:

COUNTRY*:

GRAD. DATE*:

DEGREE*:

III. PROFESSIONAL TRAINING

1. TYPE

PROGRAM*:

FROM*:

TO*:

HOSPITAL*:

CITY*:

STATE*:

COUNTRY*:

ZIP CODE*:

2. TYPE

PROGRAM*:

FROM*:

TO*:

HOSPITAL*:

CITY*:

STATE*:

COUNTRY*:

ZIP CODE*:

1a. SPECIALITY

PROGRAM*:

FROM*:

TO*:

HOSPITAL*:

CITY*:

STATE*:

COUNTRY*:

ZIP CODE*:

2b. SPECIALITY

PROGRAM*:

FROM*:

TO*:

HOSPITAL*:

CITY*:

STATE*:

COUNTRY*:

ZIP CODE*:

IV. FELLOWSHIP IN CARDIAC & VASCULAR INTERVENTIONS / SURGERY

3a. SPECIALITY

PROGRAM*:

FROM*:

TO*:

HOSPITAL*:

CITY*:

STATE*:

COUNTRY*:

ZIP CODE*:

3b. PERCENT OF TIME SPENT

PERCENT OF TIME SPENT*:

PERCENT VASCULAR/INTERVENTIONAL*:

PERCENT OTHER*:

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

SPECIALTY*:

DATE RECEIVED*:

VI. CURRENT MEDICAL LICENSURE

1.

STATE*:

LICENSE NUMBER*:

DATE OF CERTIFICATION*:

2.

STATE*:

LICENSE NUMBER*:

DATE OF CERTIFICATION*:

VII. CURRENT AND PAST PRACTICE ACTIVITIES

1.

HOSPITAL*:

CITY*:

STATE*:

COUNTRY*:

TITLE*:

HRS/W*:

DATES FROM*:

DATES TO*:

HOSPITAL*:

CITY*:

STATE*:

COUNTRY*:

TITLE*:

HRS/W*:

DATES FROM*:

DATES TO*:

HOSPITAL*:

CITY*:

STATE*:

COUNTRY*:

TITLE*:

HRS/W*:

DATES FROM*:

DATES TO*:

HOSPITAL*:

CITY*:

STATE*:

COUNTRY*:

TITLE*:

HRS/W*:

DATES FROM*:

DATES TO*:

2. PERCENT OF TIME SPENT

PERCENT OF TIME SPENT*:

PERCENT VASCULAR/INTERVENTIONAL*:

PERCENT OTHER*:

VIII. PROFESSIONAL SOCIETIES

1.

NAME OF SOCIETY*:

TYPES OF MEMBERSHIP/OFFICE*:

DATES FROM*:

DATES TO*:

NAME OF SOCIETY*:

TYPES OF MEMBERSHIP/OFFICE*:

DATES FROM*:

DATES TO*:

NAME OF SOCIETY*:

TYPES OF MEMBERSHIP/OFFICE*:

DATES FROM*:

DATES TO*:

2. MEMBER OF CSI? (Check one)*:

	YES		NO

3. MEMBER OF ICC? (Check one)*:

	YES		NO

4. MEMBER OF VSI?(Check one)*:

	YES		NO

5.MEMBER OF SCAI?(Check one)*:

	YES		NO

6. MEMBER OF ACC? (Check one)*:

	YES		NO

7. MEMBER OF ESC? (Check one)*:

	YES		NO

8. MEMBER OF ASVS(Check one)*:

	YES		NO

9. MEMBER OF ISES (Check one)*:

	YES		NO

IX. OTHER QUALIFICATIONS

REMARKS CONCERNING SPECIAL QUALIFICATIONS OR RELEVENT DATA NOT INCLUDED IN ABOVE.

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)

NAME OF FELLOW IN GOOD STANDING:

YEAR APPLICANT BECAME A MEMBER OF APVS (MINIMUM 3 YEARS):

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

A. SHALL HAVE BEEN FIRST AUTHOR OF AT LEAST FIVE (5) SIGNIFICANT PAPERS ON VASCULAR INTERVENTIONS & MEDICINE WHICH WERE PUBLISHED IN PEER REVIEWED JOURNALS. 1.

TITLE *:

JOURNAL*:

DATE*:

TITLE *:

JOURNAL*:

DATE*:

TITLE *:

JOURNAL*:

DATE*:

TITLE *:

JOURNAL*:

DATE*:

TITLE *:

JOURNAL*:

DATE*:

B. SHALL HAVE BEEN INVOLVED IN FULL SUPERVISION AND TRAINING OF RESIDENTS OR FELLOWS IN VASCULAR AND INTERVENTIONAL CARDIOLOGY/RADIOLOGY/SURGERY. (PLEASE DOCUMENT THIS SERVICE BELOW – ALSO HAVE FELLOWS SUPPLY RECOMMENDATIONS ADDRESSING THIS TOPIC.)

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

(Please Check)

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

SIGNATURE OF THE APPLICANT*:

DATE*:

MEMBERSHIP FEES

Category	Yearly Membership		Life Membership
Category	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

Demand Draft No.:

Dated:

Drawn on Bank:

Branch:

Amount:

Amount in Words:

Kindly attach a brief CV of 350-400 words*:

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

IMPORTANT NOTICE

I. GENERAL INFORMATION

FULL NAME

OFFICE ADDRESS

HOME ADDRESS

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.

IX. OTHER QUALIFICATIONS

X. SPONSERSHIP

APPLICANT FULFILLS WHICH OF THE THREE CRITERIA:

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

MEMBERSHIP FEES

PAYMENT

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

MAIL YOUR FORM TO:

Dr. (Prof.) N. N. Khanna

Organising Chairman & Secretary, APVIC – VIII

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

IMPORTANT NOTICE

I. GENERAL INFORMATION

FULL NAME

OFFICE ADDRESS

HOME ADDRESS

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.

IX. OTHER QUALIFICATIONS

X. SPONSERSHIP

APPLICANT FULFILLS WHICH OF THE THREE CRITERIA:

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

MEMBERSHIP FEES

PAYMENT

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

MAIL YOUR FORM TO:

Dr. (Prof.) N. N. Khanna

Organising Chairman & Secretary, APVIC – VIII

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

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

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