EIZOC  MEMBERSHIP  APPLICATION
Please Provide details to Apply for EIZOC Membership ..
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Applicaion ID	(Please Note after successfull submission)	* Mandatory fields
Member Name	*
Address	*
City	*
Pin Code	*
State	*	Upload PHOTO & Name After
State Code		Applying for Membership
Mobile No.1	*
Mobile No. 2
Landline No.		Name in own handwriting
EMail ID	*
AIOS No.
Proposed by	*	(Name and EIZOC-ID of Proposer)
Seconded by	*	(Name and EIZOC-ID of Seconder)
Amount (Rs.)	(Rs.) *
Mode of Pmt.	*	(Cash/Cheque/Draft/Neft/Paytm)
Date of Pmt.	(dd-mm-yyyy) *
Transaction-ID		(Transaction Detail, if any)
NOTE :	1. Applicant will have to send the signed hard copy of the filled     Membership-Form by his/her own eMail to Secretariate. 2. Proposer and Seconder will be sent eMail for verification. The     Membership will be put up for ratification after receiving the     confirmation mail from Proposer and Seconder. 3. Registration Fee Rs. 2000/- to be Deposited.	EASTERN INDIA ZONAL OPHTHALMOLOGICAL CONGRESS Bank Detail: PUNJAB NATIONAL BANK TINSUKIA Chiwara Patty (TINSUKIA), ASSAM A/C No - 0053050024587 RTGS/NEFT/IFSC - PUNB0001320 PAN - AABAE1239P
		EIZOC Membership Application