Soc. Reg. No.
MH/997/2015/PUNE
Society of Neuro Vascular Interventions
Membership Application Form for LIFE/ASSOCIATE/INTERNATIONAL Member
Membership No.
IAN
ISA
CVSI
NSI
STNI
SVIN
Any Other
Please tick the appropriate and mention membership no.
Name in Full
Date of Birth Sex
Address with
Pin Code
Telephone No.
Mobile No.
Email
Qualification
No. of Years in Neuro Intervention Practice
Percentage of Practice in Neuro Intervention %
No. of Diagnostic Procedures done Independently in last 1 year
No. of Therapeutic Procedures done Independently in last 1 year
Hospitals and
Institutes Attached
Current & Past
Proposed By Seconded By
Membership No. Membership No.
Signature Signature
The above information is true to best of my knowledge and I fully agree to abide by the rules &
regulations of the society.
Signature of Applicant
Instructions for Filling Membership Form:
1. Please read all the instructions carefully.
2. Please take printout of the form, fill it in legible handwriting (name and contact details in CAPITAL LETTERS).
Please scan and send a copy to info@[Link]
3. Also send your brief CV with photograph to info@[Link]
4. SNVI has Three types of memberships :
a) Life Member: any Neurologist / Neurosurgeon who has completed at least 1 year of dedicated training in
Neurointerventions
OR
At least 6 months of training and has independently performed more than 200 diagnostic DSAs and 50
therapeutic Neurointerventional procedures after completion of training is eligible for life membership.
b) Associate Member: Any doctor interested in Stroke and Neurointervention who does not satisfy the criteria
in 4a is eligible for Associate membership.
c) International Member: Enrolment of International Member will be at the sole discretion of Executive
Committee. All foreign applications will be considered as international membership.
5. Membership Fees: are INR 10000 for Life Members, INR 5000 for Associate Members and US Dollar 250 for
International Members.
6. All applications will be screened by SNVI Executive Committee, and the membership will be rewarded as per
your eligibility for life or associate membership. The membership number will be intimated to you on receipt
of membership fee.
7. Your membership must be proposed and seconded by the existing LIFE/EC members of SNVI.
8. Cheque/DD to be made in favour of 'Society of Neuro Vascular Interventions' payable at Pune and send it to
the below mentioned address of SNVI Secretariat.
FutureArch Events
1105, Bldg 2A, H&M Royal, Sr No. 18+19, Opp Talab Factory
Kondhwa Budruk, Pune 411048 Maharashtra INIDA
Email: tasleem@[Link] Mobile No. +91 95451 19967
9. Details for Bank Transfers:
Account Name: Society of Neuro Vascular Interventions
A/C No. 32160100014009
Bank Name: Bank of Baroda
Branch: Kondhwa
Branch Address: Konark Indrayu, Shop 114-117, Near Konark Puram, Kondhwa, Pune 411048
MICR Code: 411012029
IFSC Code: BARB0KONDHW (Fifth Character is Zero)
Swift Code: BARBINBBPCB
10. For further assistance please contact SNVI Secretary Dr Anand Alurkar # +91 98223 32452
11. Any change in mailing address and contact numbers must be communicated to the secretariat.
