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Membership |
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Last Name:_____________________________First Name______________________Middle______ Date of Birth: Month__________Date__________Year___________ Sex: Male / Female Address: Home: Street: ________________________________________________ Town: _________________ State: __________ Zip: ________ Business: Street: _______________________________________________ Address in Country of Origin: ______________________________________________ Phone Numbers: Home: (____)___________________ E-MAIL __________________________________ School of Graduation: _________________________ Year of Graduation __________________________ Prof. Degrees: ? M.B.,B.S. ? M.D ? D.O. ? D.D.S. ? B.D.S. ? Other Specialty: _______________________________ Name of Spouse: First___________________________Last________________________M______ Profession: ___________________________ Bussiness Phone:(_____)_________________ Children: 1 ____________________________ Sex_______ 2 _____________________________Sex_______ 3 _____________________________Sex_______ 4 _____________________________Sex_______ 5 _____________________________Sex_______ Category of Membership: 1 Active Member $100.00 Other Affiliations: 1. ___________________________________________________________ 2. ___________________________________________________________Pledge: I____________________________________, hereby solemnly affirm that I am a Sikh, that I believe in the Guru Granth Sahib, that I believe in the Ten Gurus . I pledge to abide by the Constitution and bylaws of the "North American Sikh Medical and Dental Association". I also pledge to promote the goals of the organization to the best of my ability. Signed: ___________________________________________Date: ________________ Return form to: Gurmit Singh Chilana, M.D. 25 Shinnecock Trail, Franklin Lakes , NJ 07417 Tel.: (973) 345-9444, Fax.: (973) 345-6992 |