Society of Endoscopic and Laparoscopic Surgeons of India (SELSI)




Membership Type

Application Information


Name

Surname

Date of Birth

Nationality

Address Professional Address             Address for Correspondence
( Both are same address Please check the box)
Institution
Department
Address
City
State
Pin Code
Mobile
E-mail
Phone
Fax

Education

Ability College/University Year of Passing
MBBS
Post Graduation
Super Specialty

Are You a


Other , Please specify

MEDICAL COUNCIL REGISTRATION

Whether a Member of any other national and interational organization:

CURRENT ENDOSCOPIC / LAPAROSCOPIC EXPERIENCE:

Experience1


Experience2

Experience3

Was laparoscopic surgery a part of your postgraduate traning,if yes , name of institution


Have you had formal training in laparoscopic / endoscopic, if yes , where



Name of 2 Referees (Who are Full life SELSI members)

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