MEMBERSHIP FORM FOR NURSES

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Name of the Attendant-

Name of the Nursing Home/Hospital –

Address of the Nursing Home/Hospital -

PIN-

City-

State-

E-mail Id-

Contact Details-

Whether registered with Delhi Nursing Council-

Year of Registration-

Existing policy or membership with any insurance company (Yes/ No) If yes, name of Insurance Company-

Sum insured-

Name of Policy-

Any claim experience-

Any pendency or litigation relating to medical or personal-

If yes, please share the brief description about the nature and stage of litigation (this detail is required if you wish to have our membership for non-medico legal cases as well)-

If you wish to take membership for any colleague doctor/ please share their name with educational qualification-

If you get the membership for any other qualified Staff/Lab Technician. If yes, please share the details-

Any other information-

PAYMENT DETAILS-

DATE

DRAWN ON

CHEQUE NO./DD/NO

AMOUNT

NOTES

As per Services of Medins Legal LLP I hereby voluntarily declare to be a member of Medins Legal LLP for which I deposit Rs. for year/s and I am quoting my details above.

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