Membership Form Download & Autofil

Surname(Family Name) (required):

Given Name (required):

Sex (required):

Date Of Birth(required):

Professional Designation (required) :

Address for Communication (required) :

Telephone (with STD/ISD)(required) :

(O)

(R)

Mobile (with Country code):

Fax:

Email (required):

Home / Professional address(required):

Professional (state speciality) / Occupation (required):

Indicate your special interest or responsibility in the field of intellectual / development disabilities:

INFORMATION ABOUT YOUR ORGANISATION

If you already belong to any organizations or professional bodies working in the field of intellectual or development disabilities , please complete the details below for our record and communication.

Name (required):

Address (required):

(M) (required):

(O) (required):

FAX (required):

E-mail (required):

Nature of Activities (required):

Upload Photo (required):

Size of photo: 2.5 x 3.5 cm.

I wish to become a member of COMHAD & enclose membership fees for 10 years.
( Rs 2500/- for india / US $50 for Developing Countries & US $100 for Other Countries)
Kindly make Payment by Demand Draftpayable to "COMHAD" and email to us OR by NEFT/RTGS/ Online Fund Transfer as per bank details given below, Kindly inform immediately the NEFT/RTGS payment details with UTR No. by Email : dryashwantpatil@gmail.com OR by SMS on Mobile number ( WhatsApp) : 0091 9423101363

BANK DETAILS FOR ONLINE TRANSFER (NEFT/RTGS Payment)

Account Name : COMHAD
Savings Account Number : 3042127926
Bank & Branch Name : Central Bank of India, Dharampeth Branch, Nagpur 440010, MS, India.
IFSC Code : CBINO281229 , MICR Code : 440016008