ASSOCIATION OF MEDICAL CONSULTANTS … OF MEDICAL CONSULTANTS (MUMBAI) Public Trust Act. 1950, Regn....
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ASSOCIATION OF MEDICAL CONSULTANTS (MUMBAI) Public Trust Act. 1950, Regn. No. F - 7373 Bom. Societies Regn. Act XXI of 1860 Regn. No. BOM-454/81 GBBCD Main Office: 4, Ganpati Niwas, Old Police Line, Andheri (East), Mumbai 400 069. Tel: 2683 6019 / 2684 4639 Telefax: 2682 1109 E-mail: [email protected] Website: www.amcmumbai.com ENROLMENT FORM MEMBERSHIP NO. Name Dr. _________________________________________________________________ Qualifications ______________________________ Specialty ________________________ Medical Council Reg. No. ______________________ State ___________________________ Date of Birth __________________ Marriage Date ______________ Blood Group __________ Contact No. Fax ___________________ E-mail _______________________________________________________ Declaration: I am practicing exclusively as a consultant. Consulting _______________________ Mobile _________________ Residence __________________ MEMBERSHIP: ASSOCIATE / LIFE / JT. LIFE (Please enclose xerox copies of Qualifications & Medical Council registration Certificates, Change of Name(if any) SURNAME NAME FATHER’S / HUSBAND’S NAME Proposed by (Name) _________________________________________ Signature ________________ Seconded by (Name) _________________________________________Signature ________________ I would like to receive my mails at Residence / Consulting Room ----------------------------------------------------------------------------------------------------------------------------------------- _________________ _________________ President Hon. Secretary Date: Signature of Applicant Hospital Attachments: DOCUMENTS REQUIRED FOR MEMBERSHIP APPROVAL 1) Two Passport size (3x4) Photographs with white background. 2) Application form filled completely. 3) M.B.B.S Certificate. 4) Post Graduate Certificate. 5) MMC Certificate, Additional MMC Certificate, MMC Renewal 6) Marriage Certificate, if change in name. ----------------------------------------------------------------------------------------------------------------------------------------- P.T.O
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Transcript of ASSOCIATION OF MEDICAL CONSULTANTS … OF MEDICAL CONSULTANTS (MUMBAI) Public Trust Act. 1950, Regn....
ASSOCIATION OF MEDICAL CONSULTANTS(MUMBAI)
Public Trust Act. 1950, Regn. No. F - 7373 Bom.Societies Regn. Act XXI of 1860 Regn. No. BOM-454/81 GBBCDMain Office: 4, Ganpati Niwas, Old Police Line, Andheri (East), Mumbai 400 069.Tel: 2683 6019 / 2684 4639 Telefax: 2682 1109E-mail: [email protected] Website: www.amcmumbai.com
ENROLMENT FORM MEMBERSHIP NO.
Name Dr. _________________________________________________________________
Qualifications ______________________________ Specialty ________________________
Medical Council Reg. No. ______________________ State ___________________________
Date of Birth __________________ Marriage Date ______________ Blood Group __________
Contact No.
Fax ___________________ E-mail _______________________________________________________
Declaration: I am practicing exclusively as a consultant.
Consulting _______________________ Mobile _________________ Residence __________________
MEMBERSHIP: ASSOCIATE / LIFE / JT. LIFE
(Please enclose xerox copies of Qualifications & Medical Council registration Certificates, Change of Name(if any)
SURNAME NAME FATHER’S / HUSBAND’S NAME
Proposed by (Name) _________________________________________ Signature ________________
Seconded by (Name) _________________________________________Signature ________________
I would like to receive my mails at Residence / Consulting Room
-----------------------------------------------------------------------------------------------------------------------------------------
_________________ _________________President Hon. Secretary
Date: Signature of Applicant
Hospital Attachments:
DOCUMENTS REQUIRED FOR MEMBERSHIP APPROVAL1) Two Passport size (3x4) Photographs with white background. 2) Application form filled completely.3) M.B.B.S Certificate.4) Post Graduate Certificate.5) MMC Certificate, Additional MMC Certificate, MMC Renewal 6) Marriage Certificate, if change in name.
-----------------------------------------------------------------------------------------------------------------------------------------
P.T.O
AFTER APPROVAL OF MEMBERSHIPŸ Signature of PresidentŸ Signature of Hon. SecretaryŸ Managing Commitee ApprovalŸ Thanking Letter & ReceiptŸ I.D. Card
MEMBERSHIP SUBSCRIPTION FEES
Life Membership RS. 8000 + 14.50% Service Tax = Rs. 9160/-Jt.Life Membership RS.12000 + 14.50% Service Tax = Rs.13740/-
Associate Life Membership Associate Jt.Life Membership
CHEQUE TO BE DRAWN IN FAVOUR OF “ASSOCIATION OF MEDICAL CONSULTANTS, MUMBAI”
RS. 8000 + 14.50% Service Tax = Rs. 9160/-RS.12000 + 14.50% Service Tax = Rs.13740/-
------------------------------------------------------------------------------------------------------------------------------------------
For Office use only:
Paid Rs. ________________ Cheque No. _____________________ Date ________________________
Bank _____________________________________________________ Branch ___________________
Sent to Bank on_________________________ Receipt No. _______________ Date _______________
Membership Approved by Managing Committee on _________________________________________
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AMC SCHEMES
?Professional Indemnity
?Network of AMC Hospitals (AMC NoAH)
?Consultants Benevolent Scheme
?Health & Accident
?Topsline (Emergency Response Service)
?Car Insurance
