Vidarbha Ophthalmic Society Membership Form

Surname

First Name

Middle Name

Email ID

Mobile Number

Date of Birth

Wedding Anniversary

Gender

Qualifications

Sub-specialty (if any)

Spouse Name

MMC Registration No

Clinic / Hospital

Phone Number

Phone Number

Passport Size Photo

Name

Membership No

Name

Membership No

Bank Details for Payment

Bank: Bank of Maharashtra

Account Number: 20108017968

IFSC Code: MAHB0000005

MICR Code: 440014002

State: Maharashtra

Pin Code: 440010

Transaction / UTR Number *

Upload Payment Screenshot *

After making payment, please enter the transaction number and upload the payment screenshot for verification.

I hereby declare that the above details are correct and I agree to abide by the rules of Vidarbha Ophthalmic Society.