Do you want to become a Life Member of ISSP

Name* Dr. Mr. Mrs. Miss.

Gender Female   Male

Upload Photo

Date Of Birth

Blood Group Select Blood Group O Positive O Negative A Positive A Negative B Positive B Negative AB Positive AB Negative

Email-Id*

Address*

Mobile*

State* Select State Andaman and Nicobar Islands Andhra Pradesh Arunachal Pradesh Assam Bihar Chandigarh Chhattisgarh Dadra and Nagar Haveli Daman and Diu Daman and Diu Delhi Goa Gujarat Haryana Himachal Pradesh Jammu and Kashmir Jharkhand Karnataka Kerala Lakshadweep Madhya Pradesh Maharashtra Manipur Meghalaya Mizoram Nagaland Odisha Puducherry Punjab Rajasthan Sikkim Tamil Nadu Telangana Tripura Uttar Pradesh West Bengal Uttaranchal

Area of Special Interest in Pain Basic Sciences Neuropathic Pain Acute Pain Cancer Pain Pain Education Interventional Pain Medicine Complimentary Medicine Others, Please specify

Others, Please specify(Please click on the check box and enter below)

College

Year Passed

University

Qualification

Name of Medical Council

Medical Council Reg No

Membership Type* Select Membership Type LM ALM

State Branch* Select State Branch Andhra Pradesh Chandigarh UT Gujarat Karnataka Kerala Madhya Pradesh Maharashtra New Delhi NONE Odisha Rajasthan Tamil Nadu Telangana Uttar Pradesh West Bengal

Additional Qualifications

Date of Registration

Primary Speciality

City Branch* Select State,First

Proposer's ISSP no*

Seconded By ISSP no*

Proposer's Email-Id*

Seconded By Email-Id*