Life / Benevolent Fund Membership Form

Haryana Civil Medical Services Association (Regd.) No. 252 dated 10th April

L. M. No………………………………………       B.F. No ………………………………….

Name__________________________________________________   Sex____________

Father / Husband Name _____________________________________________________

Date of Birth                    ………………………………………………………….                

Date of joining HCMS    .............. ………………………………………………..            

Date of retirement (age 58) ………………………………………………………..

Designation ____________________________ Institution________________________

Distt. __________________________________________ Pin ____________________

E-mail address...................................................................................................................................

Postal Address  (Can be different from official record)____________________________

______________________________________________________________________

Permanent Address _______________________________________________________

______________________________________________________________________

______________________________________________________________________

Phone Off. _______________________  Res. _________________  Mob. ___________

Nominees 1 ________________________________   Relation ____________________

     2 ________________________________  Relation ____________________

Amount (Rs) …………………………………                                             

 I agree to abide by the rules and regulations of the association

Date …………………………………..                                                     Signature of Candidate