Personal Details

1. Title Dr Dr (Miss) Dr (Mrs)

2. Name with Initials(in block capitals)

3. Full Name (in block capitals)

D D M M Y Y Y Y

4. Date of Birth

5. Civil Status Single Married

6. Address Permanent

Mailing

Official

7. Contact Details Telephone Home

Office

Mobile

E mail

Professional Details

1. Speciality

2. Date of Appointment to Grade II

3. Date of Board Certification

4. Present Place of Work

5. SLMC Registration Number

..................................... ......................................... Date Signature

P T O

ASSOCIATION OF MEDICAL SPECIALISTS

Enrolment Form

Payment of Subscription

1 You can instruct the paying authority of your institution (Accountant) to deduct Rs 3000/= annually and remit to Acct. 0007218555, Bank of Ceylon Regent Street Branch, Colombo.

2 You can pay by cash to the Treasurer of AMS and obtain a receipt.

3 You can pay to any branch of Bank of Ceylon, in favour of A/C 0007218555, Bank of Ceylon Regent street Branch

P T O