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Name (in capital letters) :

Surname Middle name First name

Date of Birth :


Academic Qualifications :

Year University

Designation :


Date/Yr of joining Anatomy :


Date/Yr of joining A.S.I. :

Ordinary member Life member

Address,Phone,Fax,E-mail, :Office Residential Permanent

Mobile No,Pager No






Position as Office bearer of A.S.I with Year:


Awards of the Society:


Other National/International Awards:


Field of Research:


Participation in International Seminar\Conference etc:



Any Special Information:

Date & Place: Signature