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Friends of Burns Centre Burns Centre Jubilee Block, Civil Hospital, Karachi. Tel.: 9215740-28 Lines (Ext. : 2459, 2483 ) Cell:0300-2760401 .

www.burnscentre.org Application Form for Ordinary / Life Membership The President / Hon. General Secretary Friends of Burns Centre Dow Medical College & Civil Hospital, Karachi Dear Sir, I wish to apply for Ordinary / Life Membership of your Society and agree by its constitution and rules as framed time to time. My Particulars are as under: Name : …………………………………………… Organization (Optional) ………………………………… Office Address: ………………………………………………………………………………………………… ………………………………………………………………………………………………………………….. Tel. (Office) ………………………… Res. : ………………………… Mobile : …………………………….. Fax : ………………………………………. E- mail : …………………………………………………………. Occupation Designation : ……………………………………………………………………………………… Proposed by : ……………………………………….. Seconded by : …………………………………………

For Office use only : Date of submitting the Application : ………………………………………………………………………… Membership Awarded : ORDINARY (Rs. 1,000/=) LIFE MEMBERSHIP (Rs. 10,000/=) Date of Acceptance : ………………………………………………………………………………………… Membership No. : ……………………………………………………………………………………………

PAYMENT INSTRUCTION (i)

Cash Rs. ________________________

(ii)

Cheque / Pay Order / Bank Draft (in favour of ‘Friends of Burns Centre’)

Membership Form  

Burns Centre

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