CMS Membership Form

And Donation

NAME:

………………………………………………………………………………………………….

ADDRESS:

· WORK

…………………………………………………………………………………………

.………………………………………………………………………………………...

·HOME

…………………………………………………………………………………………

………………………………………………………………………………………...

TELEPHONE:

· HOME ……………………………………………………………………………….………...

· WORK ……………………………………………………………………………………….....

· MOBILE…………………………………………………………………………………………

EMAIL ADDRESS: ……………………………………………………………………………………

SPECIALITY & POSITION:

……………………………………………………………………….…..

MARITAL STATUS: Married Single

CHILDREN:

Names Date of Birth

……………………. ………………………

……………………. ..……………………..

……………………. ………………………

CHURCH: ……………………………………………………………………

Signature:

Date: ……………………………………………

(Please print the form)

Please forward your membership Registration and Contribution (£10) to:

Dr.Essam Dimitry,

Furlongs

London Road,

Windlesham

Surry

JU20 6PJ

U K

Phon: 01276 479045

CMS is registered charity uk

Email webmaster@CopticMedical.com