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INDIVIDUAL MEMBERSHIP APPLICATION FORM





    I wish to apply for membership and would like to
    pay subscription for

    1 year2 year3 year4 year

    Please complete a separate from for each individual Member and fax to (033)2672 1370 or mail to: RAH Secretariat, Ruma Abedona Hospice, Rail Park, Rishra, Dt: Hooghly, W.B. – 712250, India

    MEMBER'S PARTICULARS

    Family Name*
    Title*
    Other Name
    Sex
    MaleFemale
    Profession
    Specialty

    MAILING ADDRESS

    City
    Postal Code
    State/Province
    Address
    Country


    CONTACT NUMBERS

    Cuntry Code
    Area Code
    Home
    Office
    Fax
    Mobile
    Skype
    Your Email *
    I agree to support the objectives and to uphold the values of the Ruma Abedona Hospice.

    I agree to have my name and contact details included in the Members’ Registry on the RAH Website.
    Security Check (required)

    captcha

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