Successfully reported this slideshow.
We use your LinkedIn profile and activity data to personalize ads and to show you more relevant ads. You can change your ad preferences anytime.

Membership form new

2,168 views

Published on

  • Be the first to comment

  • Be the first to like this

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

×