ABBOTTONIANS MEDICAL ASSOCIATION
MEMBERSHIP FORM
								
REGISTRATION   NO_____________

NAME ( IN BLOCK LETTERS ): -------------------------------------------------------------
FATHER’S NAME: -----------------------------------------------------------------------------
DATE OF BIRTH : ------------------------------------------------------------------------------
DESIGNATION: ---------------------------------------------------------------------------------

PRESENT ADDRESS : -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
PERMANENT ADDRESS: ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
TELEPHONE NUMBER: ----------------------------------------------------------------------
NATIONAL IDENTITY CARD NUMBER: --------------------------------------------------
BLOOD GROUP: -------------------------------------------------------------------------------
MEMBERSHIP WITH  -------------------------------------------------------------------------
OTHER ORGANIZATIONS: -----------------------------------------------------------------

ACADEMIC QUALIFICATION ---------------------------------------------------------------
AND DISTINCTIONS : -------------------------------------------------------------------------

SPORTING ACTIVITIES & -------------------------------------------------------------------
POSITION HELD: -----------------------------------------------------------------------------

SPECIAL INTEREST / TALENTS: -----------------------------------------------------------------------------------------------------------------------------------------------------------------
TENURE AT APS & C: FROM: --------------------------TO : ------------------------------
HOUSE AT APS & C : --------------------------------------------------------------------------

MEMBERSHIP REQUIRED [Please Tick]	Life Membership: Rs. 2000/-   [  ]
Cheques/ Postal orders to be made payable	Yearly Membership: Rs. 100/- [  ]
 to Abbottonians Medical Association.		Student Membership  Rs. 50/-  [  ]

SIGNATURES:-----------------------			DATE : --------------------------------

********************************************************************************
FOR OFFICE USE ONLY:
MEMBERSHIP NUMBER:----------------------------DATE OF JOINING:--------------------------------
STATUS:  LIFE MEMBER:[  ]	    REGULAR MEMBER: [  ]	      ASSOCIATE MEMBER: [  ]
LIFE MEMBERSHIP FEE:[ Rs.2000/-]	[   ]	   YEARLY MEMBERSHIP FEE:[ Rs.100/-]  [  ]
STUDENT MEMBERSHIP FEE: [ Rs. 50/-] [  ]
								Signature:--------------------------
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ABBOTTONIANS MEDICAL ASSOCIATION        Annex ‘F’
MEMBERSHIP CARD
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ABBOTTONIANS MEDICAL ASSOCIATION

 
	NAME:-------------------------------------------
	DESIGNATION: ------------------------------		
			[ FRONT SIDE ]

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AMA
NAME:-------------------------------------------------------------
FATHER’S NAME:---------------------------------------------
DATE OF BIRTH:-----------------------------------------------
NATIONAL ID CARD NO:-----------------------------------
MAILING ADDRESS:----------------------------------------------------------------------------------------------PH:--------------
BLOOD GROUP: -----------------------------------------------

SIGNATURE OF CHAIRMAN, AMA.--------------------------------