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Name *
Father/ Spouse Name *
Qualification *
Gender *
Date of Birth
Contact Person *
Designation *

Address (Residential)

Address Line1
Address Line2
Address Line3
Phone Number
Country *
Mobile *
Alternate Phone
Email *
Proof of ID PAN Card Aadhar Card
Pan Card Number *
S.No Membership Type Fees in INR Application Processing Fee
1. Life Membership (LM) 5,000 300
2. Paramedics Membership (PM) 2,000 300
3. Students Membership (SM) 1,200 300
Note: Head of the Department (HOD)/ Principal/ Registrar/ Dean/ Director CERTIFICATE of Proof of
Studentship with the Letter Head & Signature along with Official Stamp.
4. Overseas Membership (OVR) $ 200 If transferred through bank $ 5 to be added
5. SAARC Countries (SAARC) $ 125 Including Application
Processing Fee
Payment Type Online NEFT/DD / Cheque
Payment Detail: Drawn in favour of “Telemedicine Society of India” Payable at Lucknow along with Bio-Data / CV. For Online Transfer at State Bank of India”, IFSCode: SBIN0007789; TSI A/C No. 33659660395

NEFT/DD / Cheque No:
Name of Bank:
I read the Telemedicine Society of India's Bylaws and I will abide the same once I become a member.