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Name *
Date Of Birth
Gender *
Qualifications *
DegreeYear of PassingInstitute/University
MBBS
MD/MS
DM/DipNB/MCh
Others(Specify)
Address Work *
Job Title
Institution/Hospital
Address
City
Pincode
Telephone
Fax
Email
Address Home *
Address
City
Pincode
Telephone
Fax
Email
Preferred mailing address
Work     Home
Academic appointment
Full Time     Part Time     None
Primary Institutional Affiliation
Medical College/Institute
Private multispecialty Hospital
Armed Force
Solo/group practice
Professional interests (tick as many application)*
 
Adult Nephrology
Pediatric Nephrology
Pathology
Pharmacology
Urology
Hemodialysis
Transplantation
Cell/Molecular biology
Radiology
Peritoneal Dialysis
Kidney
Liver
Heart
Basic Sciences
Technical Staff
Other
Membership of other Professional Bodies
1.

2.

3.

4.
Membership No
Qualification Certificate

A ] MD/MS/DNB/PhD broad speciality or equivalent qualification certificate along with
B] DM/MCh/DNB super speciality or equivalent qualification or transplant experience certificate


Referees *
Proposed bySeconded by
Full Name
ISOT Membership no.
Email
Phone Number
Payment Type
Online    NEFT/DD / Cheque

Fee details (Rs. 4000 for Indian and US$ 400 for overseas applicants)

Payment Detail

Drawn in favour of Indian Society of organ Transplantation payable at Ahmedabad.

NEFT/DD / Cheque No
Date
Name of Bank
Branch
Dr. VIVEK B. KUTE ,Honorary Secretary, ISOT ,PROFESSOR, Dept of Nephrology,Room 124, Institute of Kidney Diseases and Research Center and Dr. H L Trivedi Institute of Transplantation Sciences ,(IKDRC-ITS), Civil hospital campus, Asarwa, Ahmedabad Pin 380016 India .Mobile: +91 9099927543, Email: drvivekkute@rediffmail.com