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    Icog Membership Form

    Uploaded by

    DrDevdatt Laxman Pitale
    This document is an application for membership to the Indian College of Obstetricians & Gynaecologists. It requests basic information from the applicant such as their name, degrees/diplomas, years of practice, publications, conferences attended, and membership references. It outlines the eligibility requirements including holding an MD for 3 years, membership in FOGSI, publications or credit points, congress attendance, paper presentations, and a membership payment of Rs. 7,500.

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    Icog Membership Form

    Uploaded by

    DrDevdatt Laxman Pitale
    72 views2 pages
    This document is an application for membership to the Indian College of Obstetricians & Gynaecologists. It requests basic information from the applicant such as their name, degrees/diplomas, years of practice, publications, conferences attended, and membership references. It outlines the eligibility requirements including holding an MD for 3 years, membership in FOGSI, publications or credit points, congress attendance, paper presentations, and a membership payment of Rs. 7,500.

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    This document is an application for membership to the Indian College of Obstetricians & Gynaecologists. It requests basic information from the applicant such as their name, degrees/diplomas, years of practice, publications, conferences attended, and membership references. It outlines the eligibility requirements including holding an MD for 3 years, membership in FOGSI, publications or credit points, congress attendance, paper presentations, and a membership payment of Rs. 7,500.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    72 views2 pages

    Icog Membership Form

    Uploaded by

    DrDevdatt Laxman Pitale
    This document is an application for membership to the Indian College of Obstetricians & Gynaecologists. It requests basic information from the applicant such as their name, degrees/diplomas, years of practice, publications, conferences attended, and membership references. It outlines the eligibility requirements including holding an MD for 3 years, membership in FOGSI, publications or credit points, congress attendance, paper presentations, and a membership payment of Rs. 7,500.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 2

    INDIAN COLLEGE OF OBSTETRICIANS & GYNAECOLOGISTS

    of
    The Federation of Obstetric & Gynaecological Societies of India
    C wing-5,6,7,9,12,13,1st Floor, D wing Entrance, Trade World Bldg., Kamala City
    S. B. Marg, Lower Parel (West), Mumbai 400 013.
    * Tel : 91 - 22 – 24951648, 24951654 * [email protected], [email protected] / www.icogonline.org

    Passport
    size Photo

    Application for Membership

    I desire to be a Member of the Indian College of Obstetricians & Gynaecologists. I hereby apply for the
    same. I am paying the Membership fee in advance. If duly elected, I shall abide by all the rules and
    regulations of the College. I hereby furnish my bio-data.

    Date of Application __________ Date of Receipt ____________ __________________


    (By Office) Signature of Applicant
    Name (in Capital) _______________ ________________ __________________
    (Surname) (First Name) (Middle Name)

    Degrees & Diplomas University / College / Institution Year of Qualifying

    Permanent Address ________________________________________________________________


    ________________________________________________________________
    _____________________________________ Pin Code No.________________
    Telephone Nos. ________________ _______________ ___________________
    (Residence) (Office) (Mobile)
    Fax No. _______________________ Email : ______________________
    Medical Council Registration Number and date,
    mentioning the name of the State Register _____________________________
    Years of practice in Obstetrics & Gynaecology _________________
    State / National/ International Conferences Attended: (Use additional Sheet of paper, if required)
    Year Place Which Congress

    Papers presented as FIRST Author at State / National / International Congresses


    (Use additional Sheet of paper, if required)
    Year Place Title

    P.T.O.
    - 2 -
    Papers Published in any recognised Journal/chapters in textbooks/articles in FOGSI Focus etc.
    (Use additional Sheet of paper, if required)
    Name of the Publication Year Volume Page Title of the Paper / Chapter /
    No. Nos. article

    Proposed by : ________________ _________________ _______________


    (Surname) (First Name) (Middle Name)
    Address : ____________________________________________________________________
    ___________________________________________ Pin Code No.___________
    Member of Society : _________________ Signature of the Proposer _____________
    Seconded by : ________________ _________________ _______________
    (Surname) (First Name) (Middle Name)
    Address : ____________________________________________________________________
    ___________________________________________ Pin Code No.___________
    Member of Society : _________________ Signature of the Proposer ______________

    To be filled by the Member Society (Certificate by the Member Society)

    This is to Certify that Dr.____________________________________ is a continuous active Member of


    the Society for the last ___________ years (Date of joining _________________ ) and holds the
    qualification mentioned above.

    __________________________ Seal _____________________________


    Signature of the President Signature of the Hon.Secretary

    To be filled in by the College Office


    Serial No._________ Date when application & Payment received _____________
    Amount Rs.______________ by Cash / Cheque /Draft
    Receipt No._____________ Date ____________
    Date when application is approved by the Governing Council _________________
    Remarks ____________________________________________________________________________
    ________________________________________________________________________
    Date and Place of the Convocation when Membership Conferred ____________________________

    _________________ _________________ __________________


    President, FOGSI-ICOG Chairperson, ICOG Secretary, ICOG

    The eligibility for the Membership is as follows : ( Kindly attach Certified copies for proof ).
    1. Holding of MD or equivalent qualification for 3 years.
    2. Membership of FOGSI.
    3. Publications of 3 papers as first author in any reputed Journal / Newsletter/FOGSI Focus OR 100
    ICOG Credit Points over any 3 years.
    4. Attendance of 2 FOGSI sponsored Congresses.
    5. Presentation of atleast 2 papers at FOGSI / FIGO / AOFOG / National / State Level Congresses as
    1st author.
    6. Membership payment of Rs.7,500/- by Demand Draft payable at Mumbai in favour of “F.O.G.S.I.”

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