NEPAL STROKE ASSOCIATION
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NSA MEMBERSHIP FORM: We Are Happy To Welcome You In The Team
Basic Information:
Salutation:
Date Of Birth:
Phone:
Address:
Choose Zone
Bagmati
Bheri
Dhawalagiri
Gandaki
Janakpur
Karnali
Koshi
Lumbini
Mahakali
Mechi
Narayani
Rapti
Sagarmatha
Seti
Choose District
Achham
Arghakhanchi
Baglung
Baitadi
Bajhang
Bajura
Banke
Bara
Bardiya
Bhaktapur
Bhojpur
Chitwan
Dadeldhura
Dailekh
Dang
Darchula
Dhading
Dhankuta
Dhanusa
Dholkha
Dolpa
Doti
Gorkha
Gulmi
Humla
Ilam
Jajarkot
Jhapa
Jumla
Kailali
Kalikot
Kanchanpur
Kapilvastu
Kaski
Kathmandu
Kavrepalanchok
Khotang
Lalitpur
Lamjung
Mahottari
Makwanpur
Manang
Morang
Mugu
Mustang
Myagdi
Nawalparasi
Nuwakot
Okhaldhunga
Palpa
Panchthar
Parbat
Parsa
Pyuthan
Ramechhap
Rasuwa
Rautahat
Rolpa
Rukum
Rupandehi
Salyan
Sankhuwasabha
Saptari
Sarlahi
Sindhuli
Sindhupalchok
Siraha
Solukhumbu
Sunsari
Surkhet
Syangja
Tanahu
Taplejung
Terhathum
Udayapur
Gender:
Male
Female
Others
Occupation:
Doctor
Nurse
Resident
Health Worker
Social Worker
Researcher
Medical Student
Proof Of Identity:
(Copy Of Citizenship/Passport in .jpg, .jpeg)
(Proof Of Occupation in .pdf, .docx)
Letter from the concerned authority/copy of Identity card in .pdf, .docx files)
Education:
Speciality:
Medicine
Surgery
Neurology
Neurosurgery
Others
Membership Category:
Choose Category
Life membership
Yearly membership
Choose Membership
Individuals (Social workers)
Medical and non-medical students
Trainees/Residents
Allied Health Professionals
Individuals (Physicians and Nurses)
Organizations
Feedback Section:
How did you hear about NSA?
Why do you want to join NSA?
How do you think NSA can help you?
*The membership duration will last for one English calendar year (January to December).
*All the membership fees are in Nepalese currency.
*For queries please contact:
Mr. Binod Kharel[nsa.membership@nsa.org] SAMPLE
Director, Membership Services
Nepal Stroke Association
Siddharthanagar-9, Anchalpur, Bhairahawa, Nepal
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