MEMBERSHIP FORM APPLICATION FOR MEMBERSHIP Order Number Note Life Membership (Rs 2000 + 85/- online application fee includes 2%transaction charge+ postal charges) Life Associate Membership (Rs 1500 + 75/- online application fee includes 2%transaction charge+ postal charges) Category of Health Social Work Professional * Medical Social Worker Psychiatric Social Worker Faculty of MSW/PSW Other Health Social Work Professionals Student of Health / Mental Health Social Work Qualifications * M.A. in Social Work M.A. in Social Science B.S.W M.Phil (P.S.W) M.S.W PHD(Social Work) Full Name Present Designation Sex Male Female Types of employment Permanent / Regular Temporary / Contractual Job Work Place Address (Current) Correspondence Address Mobile Number(s) Email Fields of Interest 2 3 Affix passport size colour photograph * Master Degree Certificate * Filled & Signed Membership Form * Qualifications (Bachelors degree and above) Degree/Diploma Bachelor Master Mphil Ph.D. Diploma / Certificate Degree/Diploma Bachelor Master Mphil Ph.D. Diploma / Certificate Degree/Diploma Bachelor Master Mphil Ph.D. Diploma / Certificate Degree/Diploma Bachelor Master Mphil Ph.D. Diploma / Certificate Degree/Diploma Bachelor Master Mphil Ph.D. Diploma / Certificate University University University University University Month/Year Month/Year Month/Year Month/Year Month/Year Appointments held and further experience (list all appointments held since graduation and/or completion of professional training in chronological order. Also mention here, full– time/ private practice. Designation Designation Designation Designation Designation Name and Address of the Employing Authority Name and Address of the Employing Authority Name and Address of the Employing Authority Name and Address of the Employing Authority Name and Address of the Employing Authority From(Date) From(Date) From(Date) From(Date) From(Date) To(Date) To(Date) To(Date) To(Date) To(Date) Refund and Cancellation Policy No Cancellation and Refund is Applicable Declaration * I Solemnly affirm that: I will uphold the aims and objectives of the All India Association of Medical Social Work Professionals to the best of my ability and agree to abide by its constitution and by-laws, which come into force from time to time.
