AIIMS NAGPUR FACULTY FORUM (ANFF)

Membership Form

Name: ___

Designation & Department: __ Photo

Qualification: _

Date of Joining: __

Address: Home: __________

Office: __________________________________________

Phone:(o) _(M) __ Email: ___________

Hobbies (Optional):

I wish to be considered for Life Membership of the AIIMS Nagpur Faculty Forum (ANFF).
I agree to contribute 1000 Rs/- as Life Membership fee and 600 Rs/- biannually as an annual
renewal fee for ANFF through NACH mandate (ECS facility). My bank details are as follows:
Account Name:
Account Number:
Bank Name:
IFSC Code:
Bank Address:

Signature

Date & Place

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(For Office Use Only)

Life Membership of Dr______________________________ is approved on and shall bear

FAAN Life Membership number as ____________.

President General Secretary

ANFF ANFF
 Instructions for Applicants

1. Please fill the form completely.

2. Form should be filled in legible handwriting.

3. Applicants should fill ALL the personal details asked for.

4. Please provide your preferred Mobile Number and Email Id. This would help us to communicate
with you in a better and faster manner.
5. Annual Renewal Membership fee can be paid by NACH Bank Transfer only.

6. Please send the duly filled form along with fee/ fee details to: The President/ Secretary,
ANFF.