Uveitis Society (India)

Name as to appear on the certificate :

Mobile Number :

Email :

Date of Birth :

Gender M/F :

Hospital / Institution name :

City :

State :

Pincode :

Address for communication :

Department :

Designation :

Upload Medical Council certificate (Size of the file must be less than 100 KB) (Format of the file must be in JPEG,JPG and PDF format) :

Upload Passport size photo (Size of the file must be less than 100 KB) (Format of the file must be in JPEG, JPG andPDF format) :

Highest Medical Qualification and Year :

Years of Practice in Ophthalmology :

Years of Practice in Uveitis :

Do you have formal training in Uveitis? :

Number of scientific publication in Uveitis in peer reviewed journals :

Number of scientific presentations :

Number of USI meetings attended in last 5 years :

References:

Note: Reference should be an USI member(2)

1. Name of Member :

US(I) Membership No :

2. Name of Member :

US(I) Membership No :

State Medical Council Reg No :

Medical Council :

Amount :

INR