SEAASM | South East asian academy of sleep medicine

DEMOGRAPHICS

Name(Professor/Dr) *

Date Of Birth *

Age *

Gender *

Speciality *

Email *

Mobile No *

Mobile No (Optional)

Mailing Address *

City *

State *

Country *

Pin Code *

MCI Registration No./ DCI Registration No.

State Medical Council Registration No./ State Dental council Registration No

ACADEMIC QUALIFICATIONS

Degree *

Institution *

Year Of Passing *

Fellowship

Institution

Year Of Passing

Membership

Institution

SLEEP MEDICINE

1. Training In Sleep Medicine

Name Of Training Center

Institution

Duration / Dates

2. Experience in Sleep Medicine (No. Of Years):

3. Work in Sleep Medicine as a Percentage of Total Work

4. Papers Presented in Sleep Medicine:

DECLARATION: I hereby declare that the information given above is true, I have furnished requisite proof as and where desired. I take oath to abide to the constitution and by-laws of the (ISDA).

Eligibility criteria for Membership:

A doctor who is a MD/DNB in Respiratory Medicine from any University in South East Asian part of the globe
A Doctor who is MD/DNB in general medicine, E.N.T or neurology and also practices sleep medicine.
A doctor who is a Physician working and practicing in sleep medicine
Dentists who are interested in sleep medicine

I agree to make a payment of 5000 INR for the lifetime membership
ISDA accepts payments in mode of Online Bank Transfers (IMPS,NEFT), DD

Company Name : South East Asian Regional Academy of Sleep Medicine
Account No : 010588700000116
IFSC CODE : YESB0000105
Bank Name : Yes Bank

Branch Address : Ground Floor, SCO 25, Vidhi Plaza, Sec 14, Huda Market, Gurgaon 122001

How do you want to pay? *

IMPS/NEFT Reference No. / Demand Draft No. *

Upload Payment Confirmation Image/PDF *

PAN Number*

Invoice Date*

GSTIN(if applicable)

Online Membership Form: Doctors

DEMOGRAPHICS

ACADEMIC QUALIFICATIONS

SLEEP MEDICINE

Eligibility criteria for Membership:

I agree to make a payment of 5000 INR for the lifetime membership ISDA accepts payments in mode of Online Bank Transfers (IMPS,NEFT), DD

I agree to make a payment of 5000 INR for the lifetime membership
ISDA accepts payments in mode of Online Bank Transfers (IMPS,NEFT), DD