NIMA - MUTUAL BENEFIT SCHEME G/2, Mohan Kunj, M.J.Phule Road, Naigaon, Dadar, Mumbai ~ 400 014. Plase APPLICATION FORM FOR MEMBERSHIP | SPOUSE MEMBERSHIP. Paste FOR OFFICE USE ONLY Passport Sie MSIF File No (3.534.5em) (TYPE OR USE CAPITAL LETTERS ONLY] RUINU. Branch Photograph (Read the instructions on the reverse) Category | LM/AMISM | State ‘Surname Fist Nae Father's | Husband's Name : Date of ith Age Sox:Male [] Female Applicant's Correspondence Adres in| Phone : STD Res. Clinic Mobile Name of Nominee Relationship With Member Nominees Permanent Addiess owl | | | TT | Phone | Motile Qualification Year of Passing [Degree Diploma) Medical Colege University | Faculty Registration Numbar Year of Registration Registering Metical Coun) Board NIMA Membership : Lite [] Associate ife: Mimbersip No. Date of Enrolment : {the undersigned, hereby appl forthe Membership/Spouse Membership of National integrated Medical Association Mutual Benefit Scheme. (wiMAMeS) | do hereby declare thatthe Information given above true and tha have withheld no information regarding this application. l agree to pay ‘the moneyicontribution and fees a and winen demande as per the rule ofthe scheme which may be ammended from time to time. also understand that inthe event of my failing to do somay disqualify me rom themembership. enclose herewith a demand DraftiChequel Cash for Total amount as computed below. ‘Admission Fees ipleaseefr tothe Table onthereverse) Rs. : Security Deposit Non-refundabe) Rs. 1000.00, Annual Subscription Rs, 200.00 ‘Spouse Membership Charges f Applicable) Rs. ‘Dank Charges (as mentioned onthe reverse) fs (Rupees. Total Rs. | have carefully read the conitions laid down inthe constitution of the Mutial Benefit Scheme approved By the National Integrated Medical Association and agre to abideby them. Signature of Introduce Applicant's Signature: Name oftroduce |: Date of application MBS Member No, PTON.B.:1) Proof of Birth Date. 4)NIMA Life Membership Certificate willhave tobe submitted bythe applicant before joining the Scheme. 2)Degree(Diploma 3) The Registration Certificate of the Medical Council/Board 5) Marriage Certificate OR Affidaut For Spouse Membership) ‘Xerox copies ofthe above produced along with verifiedby the Local Secretary President signature with Rubber stamp of Local Branch. 1, Members under the age of 30 yrs. 2. Members aged between 31835 yrs 3. Members aged between 36 & 40 yrs 4, Members aged between 41 & 45 yrs 5. Members aged between 45 & 50 yrs 6. Members aged between 81 & 55yrs 7.Members aged between 56 & 60 yrs Special Note: 1, Demand Drafts / Multi City Cheque/ Cash payable in Mumbai Office are accepted. Adm. Fee Rs. 100)- Rs. 150)- Rs. 200)- Rs. 250): Rs. 300)- Rs. 350): Sec. Depo. 1000 1000 1000 1000 1000 1900 Rs.400/- + 1000 (Admission fees and Security Deposit once paid will not be refunded) Annual Contribution Total 200 200 200 200 200 200 200 2, Incase of out station Cheque: Add Rs. 100/-as Bank Charges Extra, 3. Cheque/ DD tobe drawnin favour of "NIMA-Mutual Benefit Scheme” Payble at "Mumbai." 4. Bank Of India , Pare! Branch, Mumbai A/C No.008310100008151 5. M.0.willnot be acceptedin any Circumstance, Thisis to CERTIFY that DR. = 1300 = 1350/- ~ 14001: = 1450). = 1500/- = 1550: = 1600/- IFSC Code: BKID0000083 CERTIFICATE is Life Associate Life member of National Integrated Medical Association.. of NIMA... _» State from Date... Date: Signature Name Hon. Secretary / President. (Rubberstamp of Local Branch) : Office Use = Received on Payment By : Approval by = Receipt No. Date: Remark if any: