KERALA PRIVATE HOSPITALS' ASSOCIATION (Reg No: T/C 685/97)
(MODERN MEDICINE)
KPHA HEAD QUARTERS, THRISSUR, KERALA STATE

Membership No:
MEMBERSHIP APPLICATION FORM
Membership applied through : District Branch
To: The Hon: General Secretary,
Kerala Private Hospitals' Asociation (Mordern Medicine), Head Quarters, Thrissur, Kerala.
Sir,
The Management of hereby apply to be enrolled the Hospital as a member of the Association through the District Branch.
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1. Name of the Hospital :
(In Block Letters)
2. Address :
3. Telephone Numbers : Mobile :
: E-mail address :
4. Type of Management : Single owner/partnership/Private or Public Ltd. Co./Others
(Give details) :
5. No. of beds at present :
6. Type of Hospital in Membership Category :
7. Number of representatives deputed : (Attach a list of representatives with their full address, designation, E-mail address, Telephone/ Mobile numbers)
8. Name of the Punchayat/ Muncipality/ Coporation in which the Hospital is situvated :
9. The year of Establishment of the Hospital :
10. The specialities functioning in the Hospital :
11. Any Special facilities/ equipments provided :
Payment Terms  
12. DD No : DD Date:
13. Amount :
14. Bank : Branch
The Management here by declare that the facts given above are correct and the representatives Deputed are in accordance with the Rules laid down in the Byelaws of KPHA.
Date    :
Place   :

Signature
For Management
Certified that I have verified the eligibility of the Institution to join as a member of the Association and recommend that it may be admitted as a New Member/re-admitted as member.
Secretary District Branch
Forwarded to HQ on :
With HQ's Share Rs  :
Received HQ's Rs.
and copies returned to
Branch Secretary & Member
Hon: General Secretary
NB: Please provide the bank & DD/Cheque details correctly while submitting the form for further clarification. KPHA shall not be liable for inconsistencies or errors concerning the User information.Please write your name & details at the back of the Cheque /Demand Draft.