Name:

 Sex:   Male   /   Female

Date of Birth:

dd / mm / yyyy

Designation:

Address:

City:                                                    Country:

Phone:

Country Code - City Code - Number

Fax:

Country Code - City Code - Number

E-mail:

Field of Work:

(Please attach a brief CV)
I would like to join the Indian Peptide Society as a Student/ Life member. 

I am enclosing a Bank Draft No. ___________________, in favor of "Indian Peptide Society" payable at New Delhi, drawn on ________________ (Bank Name) for the sum of 

Rs. 500.00       [for 5-year Student Membership] 
Rs. 1500.00     [Life Membership for Academia / Corporate Members] 
US $ 100.00     [for overseas applicants].

Please enroll me as a member of the Society.

Signature:

Date:                                   dd / mm / yyyy

Please mail the form and the payment along with a copy of your CV to:

Prof. V S Chauhan 
Director, ICGEB, New Delhi
President, Indian Peptide Society 
International Centre for Genetic Engineering and Biotechnology (ICGEB) 
ICGEB Campus, Aruna Asaf Ali Marg, PO Box 10504, New Delhi-110 067, India

---------FOR OFFICE USE ONLY. DON'T WRITE BELOW THIS LINE---------

Receipt No:

Issued on:                                          

Issued by Mr. Venkat R. Kalavakolanu, Treasurer 
CMD, Jupiter Biosciences Ltd.,
Hyderabad.