NATIONAL STROKE ASSOCIATION OF SRI LANKA

Membership Application Form

Name: ………………………………………………………………………………………………………............
Age: …………………

Date of Birth: ……………………………………………………………

Nationality: …………………………………………………………………………………………………………..
Occupation: ………………………………………………………………………………………………………….
Residence:Address: ……………………………………………………………………………………………………..
Telephone: ……………………………………………………………………………………………
Office:Address: …………………………………………………………………………………………………
Telephone: ………………………………………………………………………………………………
Fax: ……………………………………………………………………………………………………….
Mobile: …………………………………………………………………………………………………………………
E – mail: …………………………………………………………………………………………………………….
Member Category: Health care Professional/ Patient/ Care Giver/ Well wisher
Life Membership: Sri Lankan residents) (Rs 2500.00):

Date: …………………

Signature ……………………………………………

Please send a cheque in favour of “NATIONAL STROKE ASSOCIATION OF SRI LANKA” to the
National Stroke Association of Sri Lanka, No.6, Wijerama Mawatha, Colombo 7, or pay by
cash at the NSASL Office.

___________________FOR OFFICE ONLY________________________ Membership No: …………………………………………………………………………………………………… Period: ………………………………………………………………………………………………………………….. Type of Membership: ……………………………………………………………………………………………. ………………………………… Secretary .

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