MEMBERSHIP FORM

I wish to become a member of the Society of Pharmacovigilance, India. I have read the constitution of the academy and agree to abide by it.

1. Name:

2. Educational Qualifications:

3. Address

(i) Office with phone #

(ii) Residence with phone #

(iii) E-mail:

4. Are you actively engaged in work concerning Pharmacovigilance:

5. Field of specialization:

6. Type of membership desired:

Life   1000/-     Ordinary 250/- 

Date:                                                                                                                                           Signature

Note: (1) The admission fee of Rupees Fifty only shall be chargeable at the initial admittance to the society. The subscription for Life membership is Rs. 1000/- only. Ordinary membership subscription is Rs.250/-, valid for calendar year and shall become due on the 1st January each year. (2) All the payments be made either in cash, or a demand draft in favour of ‘TREASURER Society of Pharmacovigilance, India', and should be sent along with this form completely filled and mailed to the treasurer. Please add Rs. 30/- for outstation cheques.

(Dr. Govind Mohan)

Treasurer

Deptt of pharmacology

S.N. Medical College

Agra-282002 (UP), India

For Office Use Only

Membership No……....…..                                  Type of membership: ……….....…

Date:                                                                                Treasurer

For queries or details, visit the website: www.medbeats.com/sopi.html