NATIONAL NEONATOLOGY FORUM

Karnataka State Chapter

Membership form

NNF-Karnataka membership #, if known: __________________________

member

New

Name: Dr / Mr/ Ms / Mrs.

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Age: ________ years
Gender: M / F

Date of birth: ___________________

Organizational/Institutional Affiliation:
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Designation:
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Educational Qualification (with Year of Passing/KMC registration number):
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Areas of interest:
Home Address with pin code:

Hospital/Institution address:

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Phone: (STD code) ________________________
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Mobile:

Email id:
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Amount paid by Cash/DD in favor of NNF Karnataka, payable at Bangalore: INR
___________________

Online transfer transaction number and date:

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Online transfer details: Account name: National neonatology forum- karnataka
branch;
Account number: 19830100005092; RTGS/NEFT IFSC CODE: BARB0BYRASA ( Fifth
character is zero); Bank : Bank of Baroda; Branch : BYRASANDRA.
Please write your name in the memo section while doing online transfer.
Lifetime Membership fees: Rs. 1500;
For students: Rs 750 (letter from
institution required)
Nurses: Rs 500 (letter from institution required)
Address for correspondence
Dr. Archana Bilagi, Secretary, State NNF
473, 5th Main Road, HMT layout,
Anandnagar, Bengaluru- 560024
Email: nnf.kar@gmail.com

Signature __________________________

Date: _____________________________