|
Medical
Computer Society of India |
| A-113,
Anna Nagar, 3rd Avenue, Chennai - 600 102, India |
| www.mcsindia.com
email : [email protected] |
| Tel
: 044 - 26207000, 26263378/79 Fax : 044 - 26263477 |
Membership
Form
(Please Fill in CAPITALS) |
| |
| Full
Name (Underline Surname) |
: |
|
| Date
of Birth |
: |
|
| Sex
|
: |
Male / Female |
| Qualifications |
: |
|
| Address
for Correspondence |
: |
|
| Telephone
- Hospital / Office |
: |
Fax No. : |
| E-mail
Address |
: |
|
| Name
and Address of Hospital / Company / Institutions |
: |
|
|
| Areas
of Interest (Please Tick One or More) |
| 1. Medical
Education |
2.
Telemedicine |
| 3. Hospital
Management Information System |
4. IT
Healthcare Security / Legal issues |
| 5. Health
portals |
6. EMR |
| 7. Imaging
Solutions |
8. Healthcae
Business Solutions |
| 9. Medical
Transcription / Call centers |
10. Others
(Please Specify) |
| Membershp
Category (Please Tick One) |
|
Type of
Membership |
Indiividual |
Organisations
/ Corporates (Upto 3 Nominees) |
| 2
Years |
Rs.
500/- |
Rs.
2000/- |
| 5
Years |
Rs.
1000/- |
Rs.
3500/- |
|
(Make
Cheque / Bank drafts payable to "MEDICAL COMPUTER SOCIETY OF
INDIA" & send it to the above address. List two Referees
for your membership with addresses / Telephone Nos and e-mail addresses
at the back of this form, otherwise membership will not be considered) |
| I will
abide by the rules and regulation of the society, if i fail to do so or
if do not pay my outstanding dues to the society my membership may be
cancelled at any time. |
| Place : |
| Date
: |
Signature |
| (Please note you will receive
an intimation of your membership status within three to four months of your
application) |
|
