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Application Forms

Individual Affiliateship Form
Organizational Affiliateship Form
Association Affiliateship Form
Institutional Affiliateship Form
"Friend" Membership Form

INDIVIDUAL AFFILIATESHIP FORM

Indian Confederation for Healthcare Accreditation (ICHA)
(Regd. Office: 4304, Gyan Shakti Apts.,Plot 7, Sector 6, DWARKA Phase-I New Delhi 110075

C/o Dr. Akhil K. Sangal,
D II / A - 2496, Netaji Nagar
New Delhi - 110 023 INDIA.
E- mail: [email protected]
Web page: www.indmedica.com/icha

Dear Sir,

I wish to register with the Indian Confederation for Healthcare Accreditation (ICHA) as Individual Affiliate after having understood the purpose/ proposed activities of this Not for profit Section 25 Co

My Cash/ Cheque/DD No.______ for Rs.1,000/- drawn on ________dated_________

payable at Delhi favoring Indian Confederation for Healthcare Accreditation is enclosed herewith. I understand this application is subject to approval by ICHA. I agree to abide by the Memorandum and Articles of Association of ICHA.

My particulars are:

Name:
Designation:
Age:
Date of Birth:
Address:
Residence:
Institution:
(Pl. tick address for Correspondence)

Telephone: Fax:

E-mail address:

Specialty& Association affiliation:
(Membership No. if any)

I would like to contribute to (Please tick all applicable)

  • Writing of processes of Healthcare delivery
  • Standards development
  • Assessor
  • Faculty on Quality Management Systems
  • Others - Liaison/fund raising etc.

I am willing to undergo appropriate training/participate in workshops as necessary. I shall provide my detailed CV when asked for.

Yours truly,

(            )

(For a Printer friendly version of the Individual Affiliateship Form, click here.)

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ORGANISATIONAL AFFILIATESHIP FORM

(Regd. Office: 4304, Gyan Shakti Apts.,Plot 7, Sector 6, DWARKA Phase-I New Delhi - 110075

Indian Confederation for Healthcare Accreditation (ICHA)

C/o Dr. Akhil K. Sangal,
D II / A - 2496, Netaji Nagar
New Delhi - 110 023 INDIA.
E- mail: [email protected]
Web page: www.indmedica.com/icha

Dear Sir,

We, ________________ wish to register with the Indian Confederation for Healthcare Accreditation (ICHA) as Individual Organizational Affiliate after having understood the purpose and proposed activities of the Not for profit Section 25 Co.

Our Cheque/DD No. for Rs.10,000/- drawn on_____ dated _____

payable at Delhi favoring "Indian Confederation for Healthcare Accreditation" is enclosed herewith. We understand this application is subject to approval by ICHA. We agree to abide by the Memorandum and Articles of Association of ICHA.

The particulars of our designated person are:

  1. Name: Designation: Age:
  2. Date of Birth:
  3. Address: Residence:
  4. Institution:

(Pl. tick address for Correspondence)

 3. Telephone: Fax:

4. E-mail address:

5. Specialty& Association affiliation

(Membership No. if any)

6. We would like to contribute to (Please tick all applicable)

  • Solidarity and Concern to improve Healthcare Quality
  • Faculty on Quality Management Systems
  • Pilot Site for process implementation (test)
  • Process Development and guidelines
  • Others - Liaison/fund raising/Sponsorships etc.

We are willing to undergo appropriate training/participate in workshops as necessary.

Yours truly,

(            )

(For a Printer friendly version of the Organization Affiliateship Form, click here.)

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DRAFT APPLICATION ON ASSOCIATION'S LETTERHEAD

The Board of Directors,
Indian Confederation for Healthcare Accreditation (ICHA),

(Regd. Office: 4304, Gyan Shakti Aptts., Plot No.7, Sector 6, Dwarka, Phase I, New Delhi - 110 075)
Phone: 26884335, Telefax: 24679272. E- mail: [email protected]

Address for Correspondence:

C/o Dr. Akhil K. Sangal,
D II / A - 2496, Netaji Nagar
New Delhi - 110 023 INDIA.
E- mail: [email protected]
Web page: www.indmedica.com/icha

Dear Sirs ,

We are in receipt of your letter and the Memorandum and Articles of Association of Indian Confederation for Healthcare Accreditation, as also earlier communications in this regard.

After due deliberations and consideration our Association hereby wishes to join as a member of Indian Confederation for Healthcare Accreditation (ICHA) . We agree with the broad structure and guidelines and to abide by the Memorandum and Articles of Association.

We enclose herewith Cheque/DD no. drawn on (Bank name)*_____dated_______ for Rs 10,000 only (Rupees ten thousand only) payable at Delhi favouring "Indian Confederation for Healthcare Accreditation". We understand that this application is subject to acceptance by the Board of Directors of ICHA on our fulfilling the eligibility conditions for Membership.

We hereby nominate the following to represent our Association

Name Designation Address, Phone, E-mail

1.

Alternatively

2.

Alternatively

3.

(Please nominate a Delhi based resident representative in case the nominees are not Delhi based to facilitate attendance at meetings. The nominees (any one) may attend the meetings. Nominees would need to actively participate and contribute to the movement and take up responsibilities in the General Body, Technical Council, Board as required. They shall also register as Individual Affiliates.)*

Particulars of Association:

A copy of resolution/authorization is enclosed.

Sincerely yours,

(            )

(Authorized Signatory with Designation)

*Not required on the letter head, for indication only/ to fill the blanks.

(For a Printer friendly version of the Draft Application Form for your Letterhead, click here.)

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DRAFT APPLICATION ON INSTITUTION'S LETTERHEAD

The Board of Directors,

Indian Confederation for Healthcare Accreditation (ICHA),

(Regd. Office: 4304, Gyan Shakti Aptts., Plot No.7, Sector 6, Dwarka, Phase I, New Delhi - 110 075)

Address for Correspondence:

C/o Dr. Akhil K. Sangal,
D II / A - 2496, Netaji Nagar
New Delhi - 110 023 INDIA.
E- mail: [email protected]
Web page: www.indmedica.com/icha

Dear Sirs ,

We are in receipt of your letter and the Memorandum and Articles of Association of Indian Confederation for Healthcare Accreditation, as also earlier communications in this regard.

After due deliberations and consideration our Institution hereby wishes to join as a member of Indian Confederation for Healthcare Accreditation (ICHA) . We agree with the broad structure and guidelines and to abide by the Memorandum and Articles of Association.

We enclose herewith Cheque / DD no. drawn on (Bank name)*_____dated_______for Rs. 10,000/- (Rupees Ten Thousand only) payable at Delhi favouring Indian Confederation forHealthcare Accreditation towards subscription. We understand that this application is subject to acceptance by the Board of Directors of ICHA on our fulfilling the eligibility conditions for MEMBERSHIP.

We hereby nominate the following to represent our Institution

Name Designation Address, Phone, E-mail

1.

Alternatively

2.

Alternatively

3.

(Please nominate a Delhi based resident representative in case the nominees are not Delhi based to facilitate attendance at meetings. The nominees (any one) may attend the meetings. Nominees would need to actively participate and contribute to the movement and take up responsibilities in the General Body, Technical Council, Board as required. They shall also register as Individual Affiliates.)*

Particulars of Institution:

A copy of resolution / authorization is enclosed.

Sincerely yours,

(Authorized Signatory with Designation)

*Not required on the letterhead, for indication only/ to fill the blanks.

For a printer friendly version of the Institutional Application form, please click here.

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"Friends" Enrollment Form

(For a Printer-Friendly copy, click here)

Dear ICHA,

I, ________________ wish to register with the Indian Confederation for Healthcare Accreditation (ICHA) as "Friend" after having understood the purpose and proposed activities of the Not-for-profit Section 25 Co.

Our Cheque/DD No. for Rs.________ (Minimum Rs 500) drawn on________ dated ________

payable at Delhi favoring "Indian Confederation for Healthcare Accreditation" is enclosed herewith.

My particulars are:

Name:_____________________
Designation:________________
Age:_______________________
Date of Birth:________________
Address: ___________________
Residence: ______________________________________
______________________________________________
Place of Work: ___________________________________
(Please tick address for Correspondence)

Telephone: (Res.)______________
(work)______________________
Fax: _______________________

E-mail address:____________________________________


Address for Correspondence:

C/o Dr. Akhil K. Sangal,
D II / A - 2496, Netaji Nagar
New Delhi - 110 023 INDIA.
E- mail: [email protected]
Web page: www.indmedica.com/icha

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