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: amcmumbai@gmail.com 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 _________________________________________

-----------------------------------------------------------------------------------------------------------------------------------------

AMC SCHEMES

?Professional Indemnity

?Network of AMC Hospitals (AMC NoAH)

?Consultants Benevolent Scheme

?Health & Accident

?Topsline (Emergency Response Service)

?Car Insurance