Association of Medical Consultants, Pune(Affilated to Association of Medical Consultants, Mumbai)

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.

Residence __________________ Consulting _______________________ Mobile _________________

MEMBERSHIP: LIFE / JT. LIFE

(Please enclose xerox copies of Qualifications & Medical Council registration Certificates, Change of Name(if any)

NAME FATHER’S / HUSBAND’S NAMESURNAME

Proposed by (Name) _________________________________________ Signature ________________

Seconded by (Name) _________________________________________Signature ________________

I would like to receive my mails at Residence / Consulting Room

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_________________ _________________President Hon. Secretary

Date: Signature of Applicant

Hospital Attachments:

DOCUMENTS REQUIRED FOR MEMBERSHIP APPROVAL1) Two Passport size (3x4) Photographs with white background2) Application form filled completely3) M.B.B.S Certificate4) Post Graduate Certificate5) MMC Certificate, Additional MMC Certificate, MMC Renewal6) Marriage Certificate for Joint Life Membership or Change in Name

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P.T.O

Office: Tel: 020-66285000 E-mail: amcpune2017@gmail.com

Noble Hospital, 153, Magarpatta City Road, Hadapsar, Pune - 411013.

Main Office: 4, Ganpati Niwas, Old Police Line, Andheri (East), Mumbai 400 069.Tel: 2683 6019 / 2684 4639 Mob: 9867450066E-mail: amcmumbai@gmail.com Website: www.amcmumbai.com

Pune

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. 10000/-Jt.Life Membership Rs.15000/-

CHEQUE TO BE DRAWN IN FAVOUR OF

“ASSOCIATION OF MEDICAL CONSULTANTS, PUNE”

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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