Membership Form

Blood Bank Name

Address

Phone no.

Fax no.

E-mail

Website

License no.

Date

Personal Information

Trustee

M.O.Incharge

Payment Information

Cheque/Demand Draft no.

Bank Name

Branch

City

Amount

Mr./Dr./Ms./

Post of

Personal Details:

Name of Medical Officers :

Name of Technical Supervisor :

Name of Nursing Staff (GNM) :

Name of Lab Technicians

License No.

Date of issue

Valid upto

Blood Components Licensed for:-

Name of Components:

Camp Permission by RSBTC :

Yes

No

RSBTC Status :

Yes

No

NACO Support Blood Bank :

Yes

No

A Brief about your institution

Membership held :

NOTE :- Joining Fee: Rs.25000/- (one time) + Annual Membership Fee : Rs.5000/-(every year)

Please make payment through Demand Draft/Cheque in favour of "Blood Banks Society" payable at Jaipur, Rajasthan.