OM Medicentre Private Limited

  • STAR HOSPITAL (A UNIT OF OM MEDICENTRE PRIVATE LIMITED)
  • +91-7073474757
  • admin@starhospital.co.in
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OM Medicentre Private Limited > 2-Membership Application

2-Membership Application

    Membership Application
    1. Ref. No. Ref. No./MEM/2022/
    2. Type of Membership No. of Members
    3. Panel Name (If IPD)
    4. Bank Detail Om Medicenter Pvt Ltd., Bank Name- Baroda Rajasthan Kshetriya Gramin Bank
    Bank Branch- Bhiwadi, A/c no.- 44990400000071
    IFSC code- BARB0BRGBXX, MICR Code- 301647050
    5. Payment Detail Payment Date
    6. Amount (Rs.) Billing Cycle
    7. Validity  
    8. Mem. Effective Date Mem. Expiry Date
    9.

    Individual Detail (If Individual only)
    Name Of Applicant Guardian /Corporate Name
    Postal Address
    Contact Number Email Id
    Pan Card No Aadhar Card No.
    10.

    Detail of Sub-Members
    S.N.
    Name of Sub-Member
    Gender
    Age
    PAN no
    Aadharno
    Relation with
    member
    1.
    2.
    3.
    4.
    5.
    6.
    11.
    Public Adminstrative Detail
    Name of Village / Society Name of Gram Panchayat / Muncipal
    Ward Number Name of Ward Member / Sarpanch
    Contact Number Email ID
    12.
    Contact Detail (Organisation)
    Type of Organisation Name of Organisation
    Contact Person Designation
    Department Contact Number
    Contact Email Id Website
    13.
    Remarks
    14.
    Name of Lead Provider Name of PRO

    Submitted by:
    Contact Name
    Mobile Number
    E-mail ID
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