Community Development Medicinal Unit

Community Development Medicinal Unit
West Bengal

Partner membership application form
This membership is a formal requirement of Community Development Medicinal Unit [CDMU] West Bengal before it can provide service to any not-for-profit organizations, who are registered with the Register of Societies or have other legal status. The membership is available on submission of this application form along with the nominal lifetime Registration Fee of Indian Rs. 50/- [rupees fifty], subject to acceptance of the application form by CDMU Executive Committee. You are requested to fill up this form and submit it along with the membership fee Rs. 50/- [rupees fifty] only by Cash / Demand Draft / Money Order in favor of 'Community Development Medicinal Unit'. A copy of your Society Registration Certificate, latest annual report, balance sheet and a valid memorandum of association are also required. You may fill-in the print version of this form and mail it with necessary documents to: Secretary, Community Development Medicinal Unit, 86C Dr. Suresh Sarkar Road, Kolkata - 700 014. If the online version is submitted, membership will not be confirmed till the duly filled-in print version with supporting documents reach us. [To be filled up by applicant] We are interested to become partner member of CDMU. We give below details of our organization.
Name of the organization
Registration no. and year
Full postal address
Telephone Fax Email
Website
Name of the chief functionary of the organization
Name and designation of contact person in relation to medical supplies from CDMU
Details of location to enable CDMU's delivery team to reach easily (if relevant)
Areas of activity [please indicate which activities are major]
Type of healthcare provided
Average out-patient attendance per day (if applicable)
Average indoor admission per month (if applicable)
Future plan in area of healthcare
I / We do hereby declare that the information furnished in this application form are true to my / our knowledge and I / We do hereby agree to fulfill all terms & conditions of your association to become partner member.
Name of the Applicant
Designation
Date
Send this form to:
Please fill-in the online version of this form or fill-in the print version and mail it to: The Chief Manager, Community Development Medicinal Unit, 86C Dr Suresh Sarkar Road, Kolkata - 700 014 or to The Adminsitrative Officer, Community Development Medicinal Unit, East Vivekananda Pally, Raja Rammohan Roy Road, P.O. Rabindra Sarani, Siliguri - 743 406.