Membership Registration form

As per the scheme and service of MMLSPL, I hereby voluntarily declare to be a member of MMLSPL for which I Deposited Rs.* * for year/s and I am quoting my detils below. I understand that the expenses to be incurred on Professional Insurance shall be meeted out from the above Deposit.

Full Name M/s. /Dr.*

Qualification's Details*

Hospital/Nursing Home/Clinic Address*

City*

State*

Phone Number*

Fax Detail

Residential Address*

City*

State*

Mobile Number*

Email ID*

Date Of Birth*

Upload Your Photo*

Medical Registration No.*

Have you registered your name with Local Council/Authority ? * Yes No

1) I certify that all details/ documents furnished are true.
2) I hereby also declare that I have fully understood the policy coverage details and also the services, rules and regulations of MMLSPL.
3) Membership acceptance subjected to realisation of cheque.

Membership Registration Form