APPLICATION FOR LIFE MEMBERSHIP OF THE SRI LANKA HEART ASSOCIATION Sri Lanka Heart Association offers life membership to consultants and trainees in Cardiology, Cardiothoarcic Surgery, Cardiac Electrophysiology, Paediatric Cardiology, Cardiac Aaesthesia and Cardiac Intensive Care. Please fill the following form and make a payment of Rs. 3000 to SLHA office for activation of your membership. Email Address * Name (as used in day to day communication eg Samitha Rathnayake) * Name (that should appear in official certificates Eg. R.M.S. Rathnayake) * Date of Birth (උපන් දිනය) Gender Male Female Phone number (Mobile) Phone number (Other) Home Address Place of Work (eg NHSL, LRH, DGH Polonnaruwa) * Position Area of work ඔබ සේවය කරන්නේ කිනම් ඒකකයකද? * Adult Cardiology Paediatric Cardiology Adult Cardiothoracic Surgery Paediatric Cardiothoracic Surgery Adult Cardiac Anaesthesia Paediatric Cardiac Anaesthesia Adult Cardiac Intensive Care Paediatric Cardiac Intensive Care Other Area of work Other Area of work Exact position (eg Nursing officer, Cardiac ICU) Referring Consultant (Please give the name of the cardiologist/Cardiothoracic Surgeon/ Anaesthetist you are working under for us to verify your details) Would you like to make a monthly payment to join the course? (this question is only a survey!) If you have any comments or suggestions please write it here! *
