»Membership Form

	THE HOMOEOPATHIC MEDICAL ASSOCIATION OF INDIA (REGISTERED UNDER THE SR ACT. XXI 1860 REGD. No. S/8418) Secretariat : 1, Alok Apartment, Vallabh Wadi, Near Gujarat College, Ellisbridge, Ahmedabad-6
	Form No. For:- Life Primary Member (This application must be thoroughly screened and all details checked at the unit and Branch level before forwarding to the Secretariat)
Membership proposed by Dr Unit H.M.A.I. Under Branch.
TO,   The Secretary General, The Homoeopathic Medical Association of India, Kanpur. Dear Sir, I hereby apply to be a member of The Homoeopathic Medical Association of India of unit under Branch. I have read the Rules and Regulations of the Association and I agree to abide by them.
Date: Full Name:
Place: (IN BLOCK LETTER) ------------------------------------------------------------------------------------------------------------------------------------------------
Details to be filled in by the applicant
1. Name: Dr
Father's/ Husband's Name:
E-mail Id
2. Address1:   Address2:   City     State
3. Date of Birth:   Age
4. Qualification [with name of Board/Councils/Universities or Licensing Bodies and dates of acquiring it]
5. Are you Post Graduate ? Yes No If Yes, Subject Topic of Dissertation
6. Registration / Enlistment Number   Date of Registration 1 Enlistment
7. Are you in private practice ? Yes No     if in private practice please state are you attached to any hospital and if so,     in what capacity     Are you in service? Yes No     If in service indicate your designation and the name of employer
8. If you have published any scientific paper, please state its title
Forwarded to the General Secretary