Membership Form for Society of Hand Therapy (SHT)
(Reg. under Society Act: Reg. No (Maharashtra State, Mumbai 2009 G.B.B.S.D. 2135)
Application Form for Membership of Society for Hand Therapy
Please affix a self-attested colour photograph
Name (in block letters): _______________________________________________________________
Qualification: _____________________________________________ ____
(Please enclose self-attested copies of relevant Certificates)
Address (in block letters): _________________________________________________________________________
___________________________________________________________________________
Telephone or Mobile No: __________________________________________________________________________
Email id: ___________________________________________________________________________
Name & Address of the Employer
/ Institution / Hospital:
_________________________________________________________________________________________________________________________________________________
Present Post Held:
____________________________________________________________________________
Department:
______________________________________________________________________________
Experience in Hand & Upper
Extremity Rehabilitation:
_____________________________________________________________
Topics of Interest: __________________________________________________________________________
I declare that all the particulars stated in this application are true to
the best of my knowledge and belief. In the event of suppression or distortion of any fact(s) made in the above application
form, I understand that I will be denied the membership. If already given the membership, the same will be cancelled.
Date:- _______________
Signature:- ___________________
Please return this duly filled form along with the membership subscription fee
of Rs. 2500/- to the Secretary, Society For Hand Therapy. Payment by bank draft in favour of SOCIETY FOR HAND THERAPY,
payable at Mumbai.
Registered Office:
Hemant
Nandgaonkar,
President
Society
For Hand Therapy
B/302,Heritage
Holy,
Nehru
Road,
Mulund
West,
Mumbai
400080
e-mail: indianhandtherapy@gmail.com
