Membership Form

PAKISTAN SOCIETY OF FAMILY PHYSICIANS

MEMBERSHIP FORM

P H O T O

To

            Dr. Tariq Aziz

            Prsident PSFP,

            30 A/B Tufail Road Lahore Cantt – Pakistan

Ph: 042-36674241, 0333-4225350

Email: dr_tariq_aziz@hotmail.com

Dear Sir,

I wish to enroll myself as a Member/Life Member/Renewal

Name: DR.                                                                                                                                

Father’s Name :                                               NIC.No.                                                           

Address                                                                                                                                                                                                                                                             Year of Garduation: ________________PMDC No:________________________ 

Name of Institution: ________   ___________________ Tel Clinic: _         _________________
Rec_______________Fax_____________Mobile:_______________E-mail: ___________________ 

Speciality: ______________________________________________________________ 

Any Other Information: ____________________________________________________

Date _______________      Doctor’s Signature _______________________________                           

                                                 And Stamp           

Note: Please attach Cheque/D.Draft or Cash Rs: 3000/- for Life Membership.

   Photo Copy of I.D.Card, M.B.B.S/P.M.D.C + Photographs