Membership Form

Step 1 of 3

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Title(Required)

First Name(Required)

Last Name(Required)

Your Email(Required)

Password(Required)

Date of Birth(Required)

DD slash MM slash YYYY

Gender(Required)

Nationality(Required)

Mailing Address(Required)

Address City State / Province / Region ZIP / Postal Code Country

Phone Number(Required)

Medical Qualification(s)(Required)

MBBS

DM Neurology

Other

Add Other Qualification(Required)

Registration Number with Medical Council(Required)

Please attach a copy of your registration certificate(Required)

Accepted file types: jpg, png, jpeg, pdf, Max. file size: 2 MB.

Specialty(Required)

Current Position(Required)

Institution/Hospital Affiliation(Required)

Areas of Special Interest within Headache Medicine(Required)

Indian Academy of Neurology (IAN) Life Member Number(Required)

Attach a copy of your IAN membership card(Required)

Accepted file types: jpg, png, jpeg, pdf, Max. file size: 2 MB.

Proposed By: (Name of IAN Life Member)(Required)

IAN Life Member Number of Proposer(Required)

Email of Proposer(Required)

Seconded By: (Name of IAN Life Member)(Required)

IAN Life Member Number of Seconder(Required)

Email of Seconder(Required)

Signature of Applicant(Required)

Accepted file types: jpg, png, jpeg, Max. file size: 2 MB.

Membership Fees(Required)

Payment Method(Required)

Name of Bank Cheque No(Required)

Date(Required)

DD slash MM slash YYYY

Amount(Required)

Payment Slip(Required)

Accepted file types: jpg, png, pdf, Max. file size: 2 MB.

Declaration(Required)

I hereby declare that the information provided in this application is true and accurate to the best of my knowledge. I have read and understood the Constitution and By-Laws of the Headache Society of India and agree to abide by them.