Application Form for Life Membership

Instructions

In the application form provided below, fill up each box with relevant data only.

Each applicant must insert his/her own unique and genuine email address. This means that each member must have a unique email address by which he/she can be communicated by us.

In the 'User Email' box, please insert only one email address. Do not insert multiple email addresses in it.

Likewise, insert only one mobile number in the 'Mobile Number' box of 'E. Contact' section. Do not insert multiple mobile numbers.

For the address parts in the form we have provided separate boxes for 'City/Town/Village', 'State/UT', 'PIN' and 'Country'. So, please insert the details accordingly.

Those who are applying on behalf of an Organisation or Institution or any such body, must fill up the both 'B. Personal' and 'D. Organisation' sections.

Those who are representing only self, need to fill up the 'B. Personal' section only.

A. Membership
Indian
Overseas
Individual
Organization
B. Personal
Dr.
Mr.
Mrs.
Miss
C. Professional
D. Organization

This section is only for those who are applying on behalf of an organization

This section has to be filled by only those applicants who are representing an organization.

E. Contact
G. Misc

Life Membership Fee structure

Corporate bodies = Rs 50,000;

Palliative care organisations = Rs 50,000;

Doctors = Rs 10,000;

Nurses = Rs 4,000;

Unpaid volunteers = Rs 2,000 (subject to certification by recognised institution in separate form to be send to us by post);

Social Workers / Others = Rs 2,000;

Overseas candidates = $100.

Cheques / DDs must be crossed and in favour of "Indian Association of Palliative Care", and payable at State Bank of India, AIIMS Campus, Ansari Nagar East, New Delhi - 110029, India.

Current Account No. 33808019294; IFSC Code SBIN0001536; MICR Code 110002005; Branch Code 001536; State Bank of India; AIIMS Campus, Ansari Nagar East, New Delhi - 110029.

For payment related queries, please write to nioiapc@gmail.com

Cash
Cheque
DD
Online transfer

If you have already paid the fee by online banking transfer method, please provide the transaction number in the box below.

OR, if you have made the payment by other methods, upload the transaction document or screen capture below.