Membership Registration Form - Ist Medical Scheme Clinic
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2IST MEDICAL SCHEME CLINIC
Belia Klaassen, MD
P.O. Box 2651
Ype Smit, MD
Dar es Salaam, Tanzania
Tel.+255 22 2601307/08
Fax +255 22 2600127
Mobile: 0754-783393
Email:
MEMBERSHIP REGISTRATION FORM
TO BE COMPLETED BY THE PRIMARY MEMBER
Last Name:
þÿ
Middle Name:
þÿ
First Name:
þÿ
Date of Birth:
Gender:
Male
Female
DD
MM
YYYY
þÿ
þÿ
þÿ
Physical Address:
þÿ
Postal Address:
þÿ
City:
Country:
þÿ
þÿ
Organization:
þÿ
Insurance
:
(if any)
þÿ
Telephone:
Home:
þÿ
Work:
þÿ
Mobile:
þÿ
Email Address:
Private:
þÿ
Work:
þÿ
Emergency
Name:
Relationship:
þÿ
þÿ
Contact:
Telephone:
þÿ
Type of
Individual: Security Deposit $200
Membership:
Couple: Security Deposit $350
Family: Security Deposit $500
Kindly state if you wish to receive invoices by:
Post
Email
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