THE COLLEGE OF OPHTHALMOLOGISTS OF SRI LANKA
Eye Hospital, Deans Road, Colombo 10. Tel/Fax 011-4710338/2693921
E-mail ophsl@isplanka.lk, ophsleye@gmail.com

APPLICATION FOR MEMBERSHIP
(Please use block letters)

Name in full:………………………………………………………………………………

Private Address:…………………………………………………………………………….

Phone:…………………. Fax:…………….. E-mail:……………………..

Date of Graduation: ………………………………………………………………………..

I, hereby apply for admission as an Affiliate / Ordinary / Life Member of the College of Ophthalmologists of Sri Lanka amnd undertake to abide by the Memorandum and Articles of Association.

Date: ……………………… Signature:…………………
Proposed by: ………………………… Signature ………………….
Seconded by…………………………. Signature…………………..

FOR OFFICE USE ONLY

Date of receipt of application: ………………………………………………………

Subscription: Affiliate/Ordinary/Life: ……………………………………………………..

Annual subscription: ………………………………………………………………………

Life subscription:…………………………………………………………………………..

Cash/Cheque (if cheque, state number and bank)
Cheque No: ………………… Bank: …………………..

Receipt No:…………………………………
………………………….
Treasurer

Date of approval by Council: ……………………….. Ledger No: …………………

Affiliate Membership Rs. 500.00 (Per Annual)
Ordinary Member Rs. 750.00 (Per Annual)
Life Member Rs.5000.00
(Payment to be made preferably by cheque in favour of “ The College of Ophthalmologists of Sri Lanka”)