PUNJAB ACADEMY OF FORENSIC MEDICINE & TOXICOLOGY
APPLICATION FOR MEMBERSHIP
(To be submitted in duplicate)
To
The General Secretary,
Punjab Academy of Forensic Medicine & Toxicology.
Dear Sir,
I want to become a Life/Annual Member of the Punjab Academy of Forensic Medicine & Toxicology. I have gone through the rules and regulations of the Academy and I agree to abide by the same. I furnish hereby the necessary particulars as required by you. Kindly enroll me as a member and oblige.
Yours faithfully,
Place: ..............................
Date: ……………………...
Signature of the Applicant
______________________________________________________________________________________
Particulars to be filled up by the Applicant:
Name (in block capital) : ……………………………………………………
Father's/Husband's Name : ……………………………………………………
Date of Birth : ……………………………………………………
Permanent Address : ……………………………………………………
Present Address : ……………………………………………………
(Subsequent change in Address should be intimated) ……………………………………………………
Phone No. : ……………………………………………………
E-mail address : ……………………………………………………
Social status : Single / Married / Widow / Widower / Divorcee
Educational Qualifications : ……………………………………………………
(With name of University and date of passing) ……………………………………………………
Registration Number, year & name of the council : ……………………………………………………
Present position in the profession : ……………………………………………………
Membership fees paid : ……………………………………………………
By Bank Draft / Cheque No. ..........................
Dated..............................................................
Signature of the Applicant
______________________________________________________________________________________
FOR USE OF PAFMAT
Membership: Accepted / Not accepted:
Date of Acceptance:
Treasurer
Secretary
Membership fees: - Rs 2000/- , Draft is sent in favor of Punjab Academy of Forensic Medicine, State bank of Patiala, RH, Patiala