Association of Physicians – Jharkhand Chapter

Member Ship Application Form

Click here to download the form in word Format

To,

The Hony Secretary,

Association of Physicians of India,

Jharkhand Chapter,

RANCHI

We here by propose the admission of

Name in full

Qualification

(Mention the branch of Medicine in which Post Graduation qualifaication is obtained)

Year of obtaining first Post Graduation qualifaication

Address

as a ____ Life Member _______ Life Associate Member of the Chapter

Membership Fee of Rs.400/-(Rs.Four hundred only) is here with forwarded by Cash/Bank Draft/Cheque, No.____________________________________________

(for out station cheque, please add Rs.60/- extra as bank charge), in favour of

"API Jharkhand Chapter" payable at Ranchi.

Signature of proposer:	Signature of Seconder:
Name:	Name:
Membership No.:	Membership No.:

Subject to approval of the Governing Body on an ordinary or a special meeting.

I agree to become a member and if admitted to abide by the rules and regulations of the

chapter.

Signature of the candidate Note of Secretary

TO BE FILLED UP BY THE CANDIDATE

Name	:
Designation	:
Date of Birth	:
Central A.P.I. Life Membership No	:
Address	:
Telephone No.	:
Mobile  No	:
E-mail	:

Mail  to the present secretary of API Jharkhand / See executive committee section.

Click here to download the form in word Format

This Form is Downloaded from www.apijharkhand.com