MEMBERSHIP FORM – SUPREME MEDICOLEGAL FORUM

Who can be Beneficiary Member(required)

Name (required)

Qualification (required)

Council Name (required)

Registration Number(required)

Membership Faculty ExpertCo-ordinatorBeneficiary (Please)

Peroid Yearly3 Years5 yearsLife Time (Phase)

IMA Member YesNo

Hospital/Clinic(required)

Institute Name(required)

Address(required)

Mobile(required)

Indemnity Insurance Bond YesNo

Email(required)

Amount Rs.(required)

Amount in words.(required)

Cheque / DD / A/c Transfer

NEFT Account Name : Supreme Medicolegal Forum

Account Number : 38016396877

Bank Name & Br. : State Bank Of India, Masulkar Colony, Pimpri.

IFSC : SBIN0016846

Account type : Current Account

(Please Mention Transaction ID Thru Mail)