Membership Enrollment Form

To
The Hon. Secretary,
Bombay Nursing Homes Association,
C/O. 101, Mangal Murthi CHS, Off S.K. Bole Road,
Agar Bazaar, Near Raheja Princess,
Dadar (W), Mumbai - 400 028.
Tel. No: 2421 1555 / 2421 2555
Fax No: 2421 3555
Email: response@bnha.in

Dear Sir,

Please enroll me as a Life Member/Patron of the Bombay Nursing Homes Association. I am sending herewith my membership fee of Rs. 4000/- and Entrance fee Rs.100/- plus Legal fund Rs.500/- (Total 4600/-) by Cheque in the name of "Bombay Nursing Home Association".

Bank Details : Account Name : Bombay Nursing Homes Association, Account Number: 004100100008993 , IFSC Code: NKGS0000004, Account Type: Current,
Bank Name: NKGSB, Bank Branch: Mahim Branch

I have read the rules and regulations of the association and I agree to abide by the same.

Yours faithfully,

Full Name (Surname First):

Membership Status:

Maharashtra Medical Council No :

Qualifications :

Telephone No:

Email : Mandatory (will be set as username) :

Password :

MCGM Ward :

"C" Form No :

Name of the hospital :

Address of the hospital :

Hospital Specialised In :

No of Beds :

Proposed By Name :

Seconded By Name :

Transaction Id for payment done of Rs 4600/- for life membership (not applicable for existing members ):

73392