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Membership form new


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Membership form new

  1. 1. Membership Form Name: Ms./Mrs./Mr. Date of Birth: (DD/MM/YY) Age (in years): Occupation: Patient/Family Member/Volunteer/Healthcare Professional/other (specify) Patients please Tick mark your illness: Sjögren's syndrome (SS)/ Lupus (SLE)/ Scleroderma/ Myositis/ RA with SS Postal Address: City: Taluka: District: State: Pin code: Tel: (R) (O) (M) E‐mail: Signature: Date: Sjögren’s India Membership Fee of Rs. 300/- may be sent by DD or cheque drawn in favour of Sjögren’s India. Please write your name and city on the back of the cheque and send to: 701, Vatsaraj, Opp. Shraddha School, Jodhpur Gam Road, Ahmedabad‐380015, Gujarat. Tel +91–79 ‐26922254 Sjögren’s India is a voluntary initiative managed by patients. Additional Contributions to support our cause may be sent by separate cheque/DD in favour of ‘Sjögren’s India’ to the above address