Membership Form

Profile (Print Legibly)

Lastname:

Firstname:

Middlename:

Suffix:

Gender:

Birthdate:

Marital Status:

PRC Number:

PRC Expiration Date:

Affiliated Organization:

Preferred Mailing Address

Residence

Hospital/Clinic

Select Any TWO council Membership that you want to get actively involved with *

Diabetes in Pregnancy
Education

Childhood Diabets
Nutrition

Foot Care
Research

Complications

Address

Chapter:

E-Mail Address:

Residential Address:

Brgy/District:

Town/City:

Province:

Residential Contact Number:

Hospital Name

Hospital Name:

Hospital Clinic Address

Hospital Clinic Address:

Brgy/District:

Town/City:

Province:

Area Code

Hospital Contact Number

Mobile Number (s) *

SMART

GLOBE

SUN

________________________________

Signature

Benefits of Diabetes Philippine (DP) Members:

>Registration fee discount in DP scientific programs.

>Free two (2) Diabetes Watch Magazines per year.

NOTE: * MUST BE FILLED UP

Membership renewal should be done on or before November 30 of the current year.

MEMBERSHIP FEE: Php 500.00/year
Option 1 CASH
Option 2 Bank Transfer

You may pay your membership fees at the branches of the following banks:

Authorized Banks:
Methrobank: S/A No. 254-3-25402919-0
PNB(Formerly) Allied Bank: S/A No. 3240020287

Check No. ________________ Issuing Bank __________________

Account Name: Diabetes Philippines

Note:

Please return accomplished form and payment to:

Diabetes Philippines Secretarist,
661 BONI AVENUE corner LIGAYA STREET MANDALUYONG CITY 1501
TEL.: 8531-1278 , 8534-9559
FAX: 8531-1278
Email:diabetesphilippines@pldtdsl.net
Webiste: www.diabetesphilippines.org

if payment was made thru bank please attach duplicate copy of your deposit slip with your application form
Only application form accompanied by payments will be processed