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PAKISTAN ASSOCIATION OF DERMATOLOGISTS
MEMBERSHIP FORM 

To,
The General Secretary,
Pakistan Association of Dermatologists.

Dear Sir,

 


I, Dr. , hereby apply to be enrolled as a Life Member of The Pakistan Association of Dermatologists. I have read the rules and regulations of the Association and agree to abide by them. My Curriculum Vitae are as follows:

 

LAST NAME

FIRST NAME

FATHER'S / HUSBAND'S NAME

ADDRESS

PHONE Residence

PHONE Clinic

PHONE Hospital

E-mail
  

MOBILE

DATE OF BIRTH

QUALIFICATIONS

 

 

PMDC Reg No.

APPLICANT'S SIGNATURE

 

 

 

 

 

PROPOSED BY

SIGNATURE

 

SECONDED BY

SIGNATURE 

 

 

 

Brig Asher Ahmad Mashood
GENERAL SECRETARY 
(2017)                   

Dr. Javed Ahmed Memon
TREASURER
(2017)

Encl:
  1. Photocopies of Degrees, Diplomas and Valid P.M.D.C. certificates
  2. A Valid PMDC Certificate is required with Endorsed Postgraduate Qualifications.
  3. 2 P.P SIZE Photographs (INCOMPLETE FORMS SHALL NOT BE ACCEPTED)

 


PAKISTAN ASSOCIATION OF DERMATOLOGISTS
DATA FORM LIFE MEMBER'S DIRECTORY

NAME
RESIDENCE ADDRESS RESIDENCE PHONE
CLINIC ADDRESS CLINIC PHONE
HOSPITAL ADDRESS HOSPITAL PHONE
E-MAIL

I WOULD LIKE TO RECEIVE MAIL AT

RESIDENCE              CLINIC              HOSPITAL
               (If any other address please give details)