application form of aimdda

ALL INDIA MD DOCTORS ASSOCIATION-AIMDDA
MEMBERSHIP APPLICATION FORM

To:



Dear Sir,
I request you to kindly enroll me/our Institution/Organization/Company/Laboratory/Clinic as Life/Student member of AIMDDA. I am providing the particulars here under-

NAME IN FULL:


QUALIFICATIONS:
Medical council registration number, Date & council:


DESIGNATION:

Contact Numbers (please indicate – landline, cell, fax)



E-Mail (mandatory):

AREAS AND FIELDS OF WORK /INTEREST:

OFFICE/RESIDENTIAL ADDRESS:


I am enclosing a crossed cheque/demand draft with Serial No…………
of Bank……………………………Place…………………………Dated……………
In favour of ‘ALL INDIA MD DOCTOR’S ASSOCIATION ’ payable at Bangalore for Rs100/1500/10000/-.
Yours truly,


Signature with name in capitals. (For institutional membership, give your designation) and Date





Subscription Rates: Till March 31st 2008-free
1. Individual Membership Yearly Rs 100 or Life membership Rs.1500/-
Institutional Membership (for any 5 nominated individuals= Life-----Rs. 10000.00
Email information mail to allindiamddoctorsassociation@gmail.com or aimddoctorsassociation@yahoo.com,and see posts at at yahoogroups.com.