Regd. No. – BAR/02544/2020-21

PRIVATE DOCTORS WELFARE ASSOCIATION

Office Address 1: Kailash Eye & General Hospital, 60 M.I.G., Janakpuri, Bareilly – 243001

Office Address 2: Mohalla Anupura Tehshil Road Aonla (Bareilly) – 243301

Contact Us: +91-7906495542, +91-9837384223, +91-8445291787 || Email ID: info.pdwa@gmail.com

MEMBERSHIP FORM

Name

Father's Name

Date Of Birth

Mobile Number

Aadhar Card Number

Postal Address

Email ID

PIN Code

Upload Photo

Upload Signature