Membership Form

Application Form for New Members
Name

Country of domicile

Nationality

Sex
Male

Female

Occupation

E-mail

Contact No.

Date of Birth

Correspondence Address

Tel. & Fax No. (International Code)

Membership Fees . Life membership $100

DASG Bank Account details

Diabetes in Asia Study Group, Commercial Bank,
A/C No. 4580 581244 001, Swift Code: cbqaqaqa,
IBAN: QA16CBQA000000004580581244001
Hamad Al Kabeer Branch , Post Box No. 3232,
Doha, State of Qatar