ACADEMY OF MEDICAL SCIENCES, NAGPUR
MEMBERSHIP ENROLMENT FORM
(2024-2025)
Full Name
Email
Mobile Number
Academic Qualification Details
Admission Year
Passing Year
Registration Number
Speciality of Practice
Date of Birth
Spouse Name
Spouse Qualification / Biodata
Marriage Date
Address
Street Address Line 2
City
State
Postal Code
Landline Number Office / Residence
#
Proposer Name
Seconder Name
1
2
Passport Size Photograph
*
Certificate
*
Please tick the Membership Type mentioned below
Life Member Couple Fees: Rs.5000
Life Member Single Fees: Rs.3000
Associate Member(MBBS+10Years in Profession) Fees: Rs.3000
Associate Student Annual Member Fees: Rs.500
Membership Fees:
5000
GST 18%:
900
Internet Handling Charge:
125
Total Amount:
Rs. 6025
Membership Fees:
3000
GST 18%:
540
Internet Handling Charge:
75
Total Amount:
Rs. 3615
Membership Fees:
3000
GST 18%:
540
Internet Handling Charge:
75
Total Amount:
Rs. 3615
Membership Fees:
500
GST 18%:
90
Internet Handling Charge:
17
Total Amount:
Rs. 607
