(Please type or print)

Name : -------------------------------------------------------------------------------------------
(Capital Letter) First Middle Last

Father's Name: -------------------------------------------------------------------------------------------
First Middle Last

Mother's Name: -------------------------------------------------------------------------------------------
First Middle Last

Address: ------------------------------------------------------------------------------------------

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Date/Place of Birth: ----------------------------------------------------------------------------------------
Day Month Year City/Country

Occupation: -----------------------------------------------------------------------------------------

Telephone/Fax/E-mail: ---------------------------------------------------------------------------------------

Reason of Joining : ------------------------------------------------------------------------------------

Type of Membership: Regular (Rs. 500/-per Annum) Life (Rs.5000/-) Patron (Rs.10,000)

(Please mark type of membership)

Signature: --------------------------------- Date: --------------------------------

Read: PBT is a purely humanitarian organization devoted to stop medical malpractice in India. Contribution/Service for PBT by any individual/group is purely "voluntary" and "not for profit". The final decision of whether or not membership for PBT will be granted to any individual/group depends exclusively on the Governing Body and the President of PBT. The Governing Body and /or the President also have the right to expel any member including the life members and the patrons from PBT at any time without showing specific reasons. The membership fee is non-refundable.