INDIAN CONTINENCE FOUNDATION
MEMBERSHIP APPLICATION
Name: _______________________________________________________________
Address: _____________________________________________________________
____________________________________________________________________
____________________________________________________________________
Date of Birth: ___________________Religion:_______________________________
Tel: (O) ________________________________(R)
___________________________
MaritalStatus_________________Nationality
:______________________ Sex: M/F
Occupation/
Present position: _ ___________________________________________
____________________________________________________________________
Areas of Interest:
______________________________________________________
____________________________________________________________________
Interest in
participating and organizing foundation’s activities: Yes/ No
Subscription: The
rates payable for different membership categories are shown below
INDIVIDUAL MEMBER
Rs 100 - entrance fee; Rs 250 annual subscription
LIFE MEMBER Rs
100 - entrance fee; Rs 1000 - one time payment
Please Note
1. Individual
memberships shall be open to all individuals and health care professionals
including patients suffering from Incontinence.
2. Corporate
membership shall be open to all commercial bodies, firms, government
organizations, clubs or any other organization interested in supporting the
foundation in furthering its aims.
3. Life
membership shall be open to all individuals irrespective of caste and creed.
4. It is
requested that you also snail mail or E mail a brief personal note of your
areas of interest with a photo for us to create your personal profile on the
website. Corporates are also encouraged to highlight their areas of interest in
incontinence and the activities planned.
Please Email /
Snail mail/ Fax application form to:
Honorary
Secretary
Indian Continence
Foundation
273/1005, I st, N
Block, 19 Th C Main, Rajajinagar, Bangalore 560 010, INDIA.
Tel: (80) 3328482/3424728, Fax: (80) 692466,
Email: icfindia@vsnl.net
Web site:
www.indiancontinencefoundation.org
Crossed cheque payable to: Indian Continence Foundation