Membership

Society Membership Application form

      

Registration No. MUZ/08024/2022-2023

Application for Membership

  1. Title:  Dr. /Mr./Ms.
  1. First name …………………………….. Middle name ………………………  Family name……………………
  1. Date of birth: ………………………………………………………Male/female…………………………………………………..
  1. Designation: …………………………………………………………………………………………………………………………………………
  1. Organization: ………………………………………………………………………………………………………………………………………

…………………………………………………………………………………………………………………………………………………………………..

  1. Address for correspondence (with PIN code): …………………………………………………………………………………………….

…………………………………………………………………………………………………………………………………………………………………..

…………………………………………………………………………………………………………………………………………………………………..

  1. Email:
  1. Tel with code________________(O)______________________     (R) ________________(M)…………………………………………………………
  1. Sponsored by existing life member of SMAHC (Mandatory for Life Members)
  1. Signature with date
  1. Name and address of Life member with membership No.

Please provide stamp size photo 

(for Life members only) 

as .jpg or word doc file
  1. Educational qualifications

Degree                 Year                                    University

13.   Professional experience

From                     To                                             Organization

14.    Area of specialization:

Research/Teaching experience                                    in years

15.    Publications (please give numbers only):                                  

  1. Books   Chapters in books             c. Research papers                   d. Review papers

16.   Awards/honours/distinctions:

17.   Detail about membership fee:

Annual Membership

Life Membership

Individual (University/Research Institute)

Corporate/ Industry

Overseas

Individual (University/Research Institute/Govt. Organizations)

Corporate/ Industry

Overseas

Membership Fee

    ₹ 200

₹ 1000

$ 100 (USD)

₹ 3500

₹ 5000

$ 500 (USD)

Admission Fee

     ₹ 50

  ₹ 100

 ₹ 350

  ₹ 500

TOTAL FEE

   ₹ 250

₹ 1100

$ 100 (USD)

₹ 3850

₹ 5500

$ 500 (USD)
  1. Payment detail- attach the scanned copy of bank transfer slip (MANDATORY)

 

  1. Name of bank …………………………………………………………………………………………………………………………………………….
  1. Amount paid: ……………………………Date………………………..Bank ……………………………………………..………………… transaction/NEFT/Ref no………………………………………………
  1. PAYMENT: Payment must be made by bank transfer only with given details as below:

Name of Bank Account: Society for Medikus and Allied Health Care (SMAHC) 

Purpose: SMAHC Membership

Bank Account number: 00000041729692748

Bank Name: STATE BANK OF INDIA 

Bank Address: Mirapur, District: Muzaffarnagar 251315

Country: INDIA 

IFSC CODE: SBIN0011438

MICR CODE: 251002010

Branch CIF No.: 91152380434

This form must be filled by typing and send as word doc by email to societyformedikus@gmail.com  or Whats app on 9520941109

Declaration:

 I certify that the above information is true and is furnished to become a member of the SMAHC. I agree to abide by the rules and regulations of the SMAHC and will abide decisions of GB of SMAHC.

Place:                                                                                                                                      Signature                                                                          Date: