Membership – AMWI INDIA

AMWI MEMBERSHIP FORM

Newsletter Form (#3)

First Name

Fathers/Husbands Name

Last Name

Qualifications

Specialty

State Medical Council No

State

Date of Birth

Blood Group

IMA membership No

Other Professionals bodies membership no.(if any)

Residential Address

Address Line 1

Address Line 2

City

State

Zip Code

Country

Consulting Address

Address Line 1

Address Line 2

City

State

Zip Code

Country

I would like to receive my Courier at:

Residence

Consulting

Residence Tel. No

Consulting Tel. No

Mobile No

Email

Proposed by Dr

Proposed by Dr

Date

AMWI NATIONAL LIFE MEMBERSHIP FEES

DOCUMENTS REOUIRED FOR MEMBERSHIP APPROVAL

CHEQUE/DD/NEFT TO BE DRAWN IN FAVOUR OF "ASSOCIATION OF MEDICAL WOMEN IN INDIA"