About Ampi & Member Profile Form

ANNEXURE: 1

Association of Medical Pharmacologists, India (AMPI) MEMBER PROFILE FORM

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Note- Columns marked with ‘*’ are compulsory.

CONTACT INFORMATION *First Name: Middle Name: Last Name: *Father’s Name: *Gender: *Marital Status: *Permanent Residential Address: *City:

*State:

*PIN Code:

*State:

*PIN Code:

*Mailing Address: *City: *Telephone: Residential: Cell Phone/Mobile: Office: *E-Mail/Web page address:

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EDUCATIONAL QUALIFICATION Degree

Year of passing

College

University

Regn. Number

MBBS MD (Minimum qualification) DM PhD Others

EMPLOYMENT- POSTS HELD (LAST FIVE YEARS ONLY) Designation

Name of Institute

Place of posting

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From (year)

To (year)

EXPERTISE AND RESEARCH INTERESTS (Tell us in which areas of pharmacology you are interested in)

Something special about yourself, you would like other association members to know

COMMENTS AND SUGGESTIONS

Thank you for completing this application form and for your interest in volunteering with us.

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Please, circulate this form (Word document must be used for submitting by e-mail) among your colleagues who clear the basic qualifications as mentioned above. This MEMBER PROFILE FORM is available for download online from the link mentioned below or can be requested by mail from the contact addresses mentioned below: http://www.orkut.com/Community.aspx?cmm=25677531 Email or post this form to the addresses mentioned below: (email is the preferred mode for application). E-MAIL ID : [email protected] Postal Address: Dr Sreekanth Gattu, Dept of Pharmacology, Sri Ramachandra Medical College, Porur, Chennai – 600116, Tamilnadu. For further assistance/information, please contact your zonal volunteers: North Zone: Dr. Kuljinder Lubana, GMC, Amritsar – 9855041700, [email protected] Dr. Kamaal CM, HIMSR, Greater Noida – 9958032288, [email protected] Dr. Dushyant, VP Chest Institute, New Delhi - 9213167336 West Zone: Dr. Narendra Bachewar, GMC, Nagpur – 9922934767, [email protected] Dr. Amit Dang, GMC, Goa – 9764001983, [email protected] Dr. Prashant Gupta, PMC, Karamsad, Gujarat – 09376150935, [email protected] Central Zone: Dr Vivek Garg, GRMC, Gwalior – 09748440626, [email protected] Dr Jamal Haider, Safdarjung, New Delhi – 9839828358, [email protected] Dr. Sashibushan Biswal, VSSMC, Orissa – 09937131899, [email protected] East Zone: Dr Subhrojyothi Bhomwick, IPGMER, Kolkata – 9830204863, [email protected] Dr. Saurav Deka, AMC, Dibrugarh – 9833659245, [email protected] Dr Kaushik Chakraborthy, RIMS, Imphal – 09436476638, [email protected] South Zone: Dr Sreekanth Gattu, SRMC, Chennai – 9940061168, [email protected] Dr S.P. Dhanya, TMC, Trivendrum – 9961132288, [email protected]

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