APPLICATION FORM FOR LIFE MEMBERSHIP

ANDHRA PRADESH CHAPTER OF

ASSOCIATION OF PHYSICIANS OF INDIA
To
The Hony. Secretary, R/No.
Andhra Pradesh Chapter of
Association of Physicians of India, Date :
Department of Medicine,
Government General Hospital, Membership No :
KAKINADA- 533001.

We hereby propose the admission :

( PLEASE FILL THE APPLICATION IN BLOCK LETTERS)
Surname

Name

Qualification Year of obtaining first Postgraduate Qualification

College

University

Permanent
Address

City / Town Dist.

Pincode Mobile

Phone (Resi) Phone (Off)

E-mail

API Membership No (National Body)

As a Life Member Associate Member of the Association (Please appropriate)

Membership Fees : Life Member - Rs. 2,000/- ; Associate Member - Rs. 1,000/-
On line remittance : Vijaya Bank, G.G.H. Branch, Kakinada - 1.A/c. No. 480201011003089. IFSC Code : VIJB0004802
Demand Draft In favour of Hon.Secretary “ The Association of Physicians Andhra Pradesh Chapter ” payable at Kakinada
(DD # Dt. Bank :

Signature of the Proposer Signature of the Seconder

Name : Name :

Membership No : Membership No :

Declaration : All the above information provided is true to the best of my knowledge.
Membership is subject to the approval of the Governing Body in an ordinary or a special meeting.
I agree to become a member and if admitted, will abide by the Rules and Regulations of the Association.
Encl : 1) Above said Demand Draft.
2) One Extra Photo for ID Card
3) Xerox Copy of MD Certificate & One Photo Copy of Proof of Identity Signature of the Applicant

Remarks : 1) Qualification : MD / DNB 2) API National Body Membership No.

For API Office Use - Scrutiny by Name Signature Dt.