Ruma Abedona Hospice

a charitable centre for cancer and palliative care

LOVE & COMPASSION

CARE Beyond CURE

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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.
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