Indian Speech and Hearing Association

Nomination Form

Indian Speech and Hearing Association
Regd. under the Karnataka Societies Registration Act.
Karnataka Act No. 17 Registration No. S 25/67-68

Nomination form for the ISHA Election: 2009-2010

*Name of the Nominee : --------------------------------------------------------------------
Correspondence Address: -------------------------------------------------------------------
Contact Phone No : ------------------------------- Mobile Number----------------
E-mail : ----------------------------------Life membership No: -------
Post applied for :--------------------------------------------------------------------
I hereby nominate Dr./Mr./Ms: -------------------------------------------------------------------
For the post of --------------------------------------------------------------------
*Proposed by Dr./Mr./Ms.---------------------------------------------------------------------------
Life membership Number--------------------------- Signature ----------------------------------
*Seconded by Dr./Mr./Ms:--------------------------------------------------------------------------
Life membership Number--------------------------- Signature ----------------------------------
Signature of the Nominee
Last date of submission of Nomination: 15.01.2009
Last date of withdrawal of Nomination: 24.01.2009
Please send the hard copy of your nomination on or before: 15.01.2009
Send separate nomination for each post
Please mail the dully filled up application form on o before 15.01.2009 to:
Dr. S.P. Goswami
Honorary Secretary-ISHA
H.O. AIISH, Manasagangothri
Mysore-570006, Karnataka
E-mail: goswami16@yahoo.com
*P.S: Enclose Xerox copy of ISHA life membership certificate

Nomination Form (Download)