www.asiindia.org
 
   
   
 
ASI Fellowship  
   
   
 

 

The Association of Surgeons of India

APPLICATION FORM FOR THE FELLOWSHIP OF
THE ASSOCIATION OF SURGEONS OF INDIA
 
 
   
 
Step 1: Personal Information  
First Name:
Middle Name:
Last Name:
Sex:
Date of Birth: / /   (DD / MM / YY)
Date of Marriage: / /   (DD / MM / YY)
Blood Group:
Email:
   
Which address below should ASI
use as your primary contact address?		 Professional
Residential
 
 
Step 2: Professional Address
Institution:
Title/Department:
Mailing Address
 
City:
District:
State :
Pin Code:
Country:
Mobile Number:
Landline Number:
 
STD Code   Number
Fax:
 
STD Code   Number
 
 
Step 3: Residential Address
 
Residential Address:
 
City:
District:
State:
Pin Code:
Country:
Mobile Number:
Landline Number:
 
STD Code   Number
Fax:
 
STD Code   Number
 

Upload
Photo
  Step 4: Medical Licensure
   
 
Registration number & Date:
  
/ /   (DD / MM / YY)

Name of the registering Council:

 
   
   
  Step 5: Education
 
Institution
Degree Awarded
Date (DD / MM / YY)
College/University:
/ /
Medical School:
/ /
Postgraduate Training:
/ /
   
   
  Step 6: Are you member of the Association of Surgeons of India
 
         
  Yes No
         
   
  ASI Number:
         
  Annual Life Member
   
   
  Step 7: Membership of Medical Societies
   
 

Sl. No
Organisation
Membership No.
Year
   
   
  Step 8: Surgical Experience after Post Graduation (in chronological order)
   
 

Sl. No
Designation
Institution
From
To
 
 
Step 9: Awards / Honours
 
 

Sl. No
Awards
Year
 
 
Step 10: Research / Experimental Work
 
Please begin with the most current.
 

Sl. No
Subject
Institution
Duration
 

Publications

Sl. No
Topic
Journal
 
 
Step 11: Conference Attended (Last five years)
 
Please begin with the most current.
 

Sl. No
Subject
Conference / Seminar
Year
 
Step 12: Declaration
 

I hereby declare that all the information given above is correct. I would like to apply for the Fellowship of Association of Surgeons of India (FAIS). I agree to abide by the rules and regulations of The Association of Surgeons of India as may be enacted from time to time.

 
Name:  
Place:    
       
Date:
/ /   (DD / MM / YY)
 
 
 
Recommendation
 
 
Recommended by 1. Dr  
ASI Membership No.  
Date:
/ /   (DD / MM / YY)
 
 
2. Dr  
ASI Membership No.      
Date:
/ /   (DD / MM / YY)
 
Recommendation should be done by two surgeons of not less than seven years standing of whom at-least one should be a member of the Association of Surgeons of India. In case of surgeons living outside India, it is enough if this recommendations is signed by any two surgeons.