Shushrusha Hospital

To,

Shushrusha Citizens’ Co-operative Hospoital Ltd.

698-B, Ranade Road, Dadar, Mumbai – 400 028.

Application Form for Membership and Shares

Sir / Madam,

I Shri / Smt / Mrs / Miss _____________________________________________ the undersigned hereby request you to admit me as a member of your society. Please allot me 100 shares.

I am sending herewith a sum of Rs. 10200/-(Ten Thousand Two Hundred Only) being Rs. 10000/- as a value of 100 shares, Rs.100/- as the cost of Family ID - card and Rs. 100/- as entrance fee.

I here gone through the Bye lows of your society and undertake to abide by them as they stand or as they might stand with modifications which may be made from time to time.

Particulars to be filled in by applicant in Block Letters.

Name in Full (Surname First)

Date Of Birth

Address

Name of Suburb

City

Pin Code No.

E-Mail

Tel. No. (Mobile)

Tel. No. (Resi.)

Aadhar Card no.

PAN No.

Occupation

Please Upload Document Jpg or Png Only.

Upload Profile Image

Upload Signature Image

Nomination (To be filled in by the applicant)

As per the requirement of the Maharashtra Co-operative Societies Act. 1960 section 30 (1) and The Maharashtra Co-operative Societies rules. 1961 - Rule No 24.

FAMILY IDENTITY CARD

Member Name (Applicant)

Date Of Birth

Spouse Name

Date Of Birth

Children Name (Upto 21 years)

Children Gender

Date Of Birth