eizoc.secretariat@gmail.com +91 943 503 6725, +91 700 246 5829



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