SRNM Membership
Join SRNM |
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Society of Renal Nutrition and Metabolism (SRNM)
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Application for the Membership
PLEASE FILL IN CLEARLY |
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| Title: Dr / Mr / Ms | ||||||
| Name : (First Name) _________________________________ (Middle Name) _____________________________ (Family Name) _____________________________ | ||||||
Professional Qualifications :______________________________________________________________________________ |
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| Institution : __________________________________________________________________________________________ | ||||||
| Corresponding Address : _______________________________________________________________________________ | ||||||
| ___________________________________________________________________________________________________ | ||||||
| City : ___________________________ State : _________________________________________Pin : _________________ | ||||||
| Tel No: Landline: STD Code : ___________ Number :______________________ Fax No :____________________________ | ||||||
| Mobile/s : ___________________________________________________________________________________________ | ||||||
| E-Mail Address :______________________________________________________________________________________ | ||||||
| Membership Fee: | ||||||
| Annual : Rs 1100.00 | ||||||
| Membership Fee to be paid as demand draft in the favour of “Society Of Renal Nutrition and Metabolism” payable at | ||||||
| Lucknow. | ||||||
| Details of the remittance : | ||||||
| Bank /DraftNo : ______________ Drawn on(Bank)___________________________________ Branch____________________ | ||||||
| City: ___________________________________ | ||||||
| Date______________ | Signature | |||||
| The application form duly signed by the applicant along with bank draft for membership fee should be sent to | ||||||
| Prof. Narayan Prasad | ||||||
| Secretary, Society of Renal Nutrition and Metabolism (SRNM) | ||||||
| Professor & Head |  |
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| Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow-226014 | ||||||
| Email: narayan.nephro@gmail.com | ||||||
| Download Membership Form | ||||||
| Website: www.srnm.in | ||||||
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