Ishms Membership Form

Name (Block Letters)

Affiliation

Address for Communication

Permanent Address

Email Id

Phone No.

Alternate Email Id

4. Particulars of date of birth and nationality

Date of Birth

Nationality

Gender

Marital Status

Family information (optional)

Father's Name

Mother's Name

Spouce

Spouce Occupation

6. Type of Membership Desired (for eligiblity please see Note 1)

Type of Membership

Membership Duration

7. Names of two referees/ supporters from ISHMS (please see Note 1)

Reffrence-1 Name

Reffrence-2 Name

8. Particulars of Qualification (In reverse chronological order)

Qualification-1

Discipline

Grades/Division/CGPA

Duration (from-to)

Institute/University

Qualification-2

Discipline

Grades/Division/CGPA

Duration (from-to)

Institute/University

Qualification-3

Discipline

Grades/Division/CGPA

Duration (from-to)

Institute/University

9. Professional Experience (In reverse chronological order)

Organisation-1

Designation

Duration (From-to)

Duration (years-month)

Duties/ Specialization

Work relevant to SHM?

Organisation-2

Designation

Duration (From-to)

Duration (years-month)

Duties / Specialization

Work relevant to SHM?

Organisation-3

Designation

Duration (From-to)

Duration (years-month)

Duties / Specialization

Work relevant to SHM?

Total Experience (Years and months)

Experience in SHM and related domains (Years and months)

10. Fee Payment Details (please see Note 2)

Basic Fee

GST (@18%)

Total amount payable

NOTE: Fee shall not be paid at the time of form submission. Application shall be evaluated by the Governing Council as per the Rules and Regulations of the Society. Fee shall be payable after successful election/ admission by the Governing Council, which shall be intimated in due course.

Writeup on your work on SHM (up to 1500 words)

(Mandatory for those selecting Fellow or Member)

Other Relevant Information if Any

Date

10. Document Upload

Instructions: File size for photograph should not be more than 100kb and for pdf should not be more than 150kb.

Pasport Size Photograph

(formats: jpg and png)

Adhaar Card (self attested)

Self attested copy Identity card of present institute/ organization.

Any other relevant document/ Bonafide certificate for students.

(Bonafied certificate is mandatory for student membership)