Official Application Portal Membership Registration Form Please fill legibly in BLOCK letters Personal & Professional Information Upload Your Photograph (JPG, JPEG, PNG only | Max 2MB) * 1. Full Name * *Required Field 2. Qualification * *Required Field 3. Speciality * *Required Field 4. Designation 5. Date of Birth (dd/MM/yyyy) * Type numbers only (slashes format automatically) *Required Field 6. Gender Male Female Contact Details & Addresses Address 1 (Official / Institution / Hospital / Clinic) * *Required a. Mobile (10 digits) * *Required b. Landline Phone c. Email ID * *Required Address 2 (Residence / Alternate) a. Mobile (alternate) b. Landline Phone c. Email ID (alternate) Medical Council Registration Medical Council Registration Number 9. Place of Registration Educational Qualifications Basic Degree (MBBS) Year of Joining Year of Passing College / Institution Degree Awarded By Degree (General Surgery) Year of Joining Year of Passing College / Institution Degree Awarded By Degree (Cardiovascular and Thoracic Surgery) Year of Joining Year of Passing College / Institution Degree Awarded By Other (degrees / qualifications / research / work) a. b. c. d. Membership Category & Declaration Membership Category Applied for * Life Member INR 12,000.00 (One-time) Life Member (by upgrade) INR 5,000.00 (For Associate Members) Associate Member (cardiac) INR 8,000.00 (One-time) Associate Member (non-cardiac) INR 8,000.00 (One-time) Overseas Life Member (SAARC countries) INR 15,000.00 (One-time) Overseas Life Member (Non-SAARC countries) USD 1000.00 Declaration (by applicant): I hereby accept to abide by the rules, regulations, and bylaws of the IACTS as per the constitution and as revised from time to time. Payment Details & Checklist 16. Membership Payment Details Mode of Payment Amount (INR / USD) Cheque / DD / Online Ref Number Date (dd/MM/yyyy) a Cash b Cheque c Demand Draft d Online Transfer 1Membership Fee Structure a. Life Member INR 12,000 b. Life Member (by upgrade) INR 5,000 c. Overseas (SAARC) INR 15,000 d. Overseas (Non-SAARC) USD 1,000 e. Associate (Cardiac) INR 8,000 f. Associate (Non-Cardiac) INR 8,000 Bank & Remittance Info Direct Bank Transfer Account Name: Society of Minimally Invasive Cardiovascular and Thoracic Surgeons of India Account Number: 36119022797 Bank Name: State Bank of India (Escorts Heart Institute Branch) IFSC Code: SBIN0010448 Cheque / Demand Draft In favour of: “Society of Minimally Invasive Cardiovascular and Thoracic Surgeons of India” Payable at: New Delhi Mandatory Submission Checklist Completed membership registration form with signature Cash, cheques, demand draft or online payment receipt Self-attested copy of MBBS degree certificate Self-attested copy of medical council registration Self-attested copy of MS/DNB degree certificate Self-attested copy of MCh/DNB degree certificate (if applicable) Self-attested copies of other educational certificates (if details provided for Sl. No. 13) Letter from Head of Department (if applying for Associate Membership)