ISCP

FELLOWSHIP EXAM APPLICATION FORM

Your Mobile No.

Name

Age

Email Id

Address (Residence)

Office

Date Of Birth

Qualification in Surgery & University:

Name of Institute

Interest in Colorectal Surgery (Number of Years)

Reg. No. ( State reg no.)

Payment Details ( DD Details )

Fellowship Fees: 15000/-

For any query please contact :- Dr. L. D. Ladukar (Secretary ISCP) +919422353085

Date:-

The form & D.D. please send to “Dr. L. D. Ladukar, Ladukar Surgical Hospital, Nagpur Road, Bramhapuri, Distt- Chandrapur – 441206” Branch Name : Central Bank of India, Bramhapuri, Account Name:- International Society of Coloproctology, Account No.: 3214676463, IFSC code – CBINO283914, MICR Code- 442016507

FELLOWSHIP EXAM APPLICATION FORM

Fellowship Fees: 15000/-

Those who are non members add 3000/- and fill the membership form.

Send the payment receipt details to Dr. L. D. Ladukar (Secretary ISCP) Whatsapp Mobile No. +919422353085, Email Id- lladukar@gmail.com