APPLICATION FORM FOR MEMBERSHIP


APPLICATION FORM FOR MEMBERSHIP
1.	First Name:		PHOTO (Max. 50 kb)
2.	Last Name:
3.	Name in Full:
4.	Date of Birth:	(DD-MM-YYYY):
5.	Designation:
6.	Employee No.
7.	Region of Association: (Where Posted)
8.	Company: (Where Posted)
9.	Email:
10.	Mobile No.:
11.	Address: A). Present Residence	Quarter No (i.e. D-151) / House No.: -
	B). Present Office
	C). Permanent Residence
12.	Date of Joining as: (A.E./Shift Chem Doct/AO/PO/WO/Other Equ/J.E./P.A./T.A./PARA MED. STAFF)	(DD-MM-YYYY):
13.	Mode of Payment
	(Rs. 200/- One time subscription fee. Yearly Subscription fee @ Rs. 300/-) Total Rs. 500/-
	The above information furnished by me is true to the best of my Knowledge. I accept that I will follow all the rules & regulation of association. I will deposit the entry fee and Life-Time subscription or membership fee to the association. I undertake to intimate about change in my cadre and posting to the Regional Secretary when such changes takes place.
14.	USER ID (firstname.lastname):	PASSWORD:
15.	Identification Proof (Upload your Company ID Card): (Max. 100 kb)	ID (Max. 100 kb)
16.	Signature (Upload): (Max. 25 kb)	SIGN (Max. 25 kb)