www.fhno.org

FOUNDATION FOR HEAD AND NECK
ONCOLOGY

(Registered under Charitable Societies Act)

MEMBERSHIP FORM

Name :

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Age / Date of Birth :

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Professional Qualification :
(With year and Institution)

____________________________________________________

Address for communication :

____________________________________________________

E-mail ID :

____________________________________________________

Present position :

____________________________________________________

Area of interest / expertise :

____________________________________________________

Type of membership : (Please Select)

	Life member (Rs.3000/-) Open to all medical professionals holding a recognized post graduate degree in the concerned specialty
	Life Associate Member (Rs.3000/-)Open to all paramedical professionals involved in the specialty
	Annual Member (Rs.300/- )-open to all
	Oncologist in training membership (Rs 1500) Open for post graduate students in the specialty. These members can request for conversion to full membership when they become otherwise eligible by paying the difference of the fees as applicable at that time.