Bombay Nursing Home Association

Membership Enrollment Form

To
The Hon. Secretary,
Bombay Nursing Homes Association,
C/O. 101, Mangal Murthi CHS, Off S.K. Bole Road,
Agar Bazaar, Near Raheja Princess,
Dadar (W), Mumbai - 400 028.
Tel. No: 2421 1555 / 2421 2555
Fax No: 2421 3555
Email: response@bnha.in

Dear Sir,
Please enroll me as a Life Member/Patron of the Bombay Nursing Homes Association. I am sending herewith my membership fee of Rs. 4000/- and Entrance fee Rs.100/- plus Legal fund Rs.500/- (Total 4600/-) by Cheque in the name of "Bombay Nursing Home Association". I have read the rules and regulations of the association and I agree to abide by the same.

Yours faithfully,

Full Name (Surname First) :

Membership Status :

Maharashtra Medical Council No. :

Qualification :

Residential Address :

Telephone Number :

Email : Mandatory (will be set as username)

Password :

MCGM Ward :

Name & Address of the Hospital :

Hospital Specialised in :

No of Beds :

Prefered Mailing Address : Tick()whichever is applicable

Residential

Hospital

Proposed By: Name

Seconded By: Name

Note: For all new members after filling the online form kindly take a print and courier along with a cheque of Rs. 4,600/- with BMC registration certificate and in charge Doctor degree certificates.