Name of City Branch ISSP: Name of State Chapter ISSP:
    Name of the Member nominated: Dr/Mr

    Academic Participation (Past 10 years):

    Contribution of the applicant in promotion of Pain

    Whether the nominee served Indian Society for Study of Pain in any capacity: (mention name of branch, post held, year)

    Whether the nominee is an office bearer of any other National/International Professional Associations – Details (President/Secretary/Governing Council member) Details of special activities if any of the nominee:
    Role in development of Institution/Development/ Work area:

    Whether the applicant ISSP winner of National/International awards/ in the Field of Medicine/ Any other awards:

    Contribution into Pain Medicine teaching (Mass teaching/CME/Courses run etc.,):

    Details of involvement in new innovative methods in the medical field in the country/ medical research done/ research associated/new service started:

    Details of outstanding service any where inside the country / outside:

    DECLARATION I, hereby give my consent for the Award ( written in this form ) of ISSP