Name : Dr./Mr/Mrs/Miss ....................................................................................................
Qualifications: .......................................................................................................................
Speciality / Designation: .......................................................................................................
Name of the Organization: ...................................................................................................
Address: ................................................................................................................................
.....................................................................................Pin Code: ..........................................
Telephone: .............................. Fax: ......................... E-mail: ..............................................
Mailing Address: ..................................................................................................................
................................................................................... Pin Code: ...........................................
Telephone: .............................. Fax: .........................E-mail: ...............................................

B. Institutional Membership:

Name of the Institution .........................................................................................................
Address .................................................................................................................................
...................................................................... Pin Code .........................................................
Telephone ................................ Fax ........... E - mail ............................................................
Nature of Business ...............................................................................................................

I / We agree to become a Life Member / Institutional Member of the HASHMI
HUMAN RESOURCES DEVELOPMENT SOCIETY of Health Administrators.

Date: .............................

Place: ............................

Signature of the applicant or seal of the Institution

Kindly indicate the mailing address: Office / Residence.
Kindly communicate change of address in future.