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REGISTRATION FORM
  • Family Name:*full name
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  • Other Names:*full name
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  • Gender:*full name
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  • Date of Birth:*make a booking
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  • Occupation*full name
    4
  • Profession*full name
    5
  • Office Address*full name
    6
  • Permanent Address*full name
    7
  • Tel:*full name
    8
  • Email*a valid email address
    9
  • Mobile*full name
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  • Fax*full name
    11
  • Scientific Desk (s) of your interest (tick)*you like
    Maternal Child Health (MCH)
    Dental Health
    Rational Drug Use
    Communicable Disease
    Environment Health
    Life Style
    Occupational Health and Safety
    Safety Promotion and Injury Prevention
    Information communication Technology (ICT)
    Human Resource for Health (HRH)
    People’s Health Movements (PHM)
    12
  • Administrative Desk(s) of your Interest (tick)*you like
    Membership &District Activities
    Government & international Organization Relations
    International Relations
    Finance and Fundraising
    NGOs / Private Sector Relations
    Publicity & information
    13
  • Which Other Desk would you like to be formed in the Association*full name
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  • Which Health Activities are you Involved in (Tick)*you like
    Health Care
    Health Administration
    Health education
    Teaching
    Research
    Others
    15
  • I am Remitting*you like
    Shs 40,000 Membership Fee
    Shs 40,000 Annual subscription (payable after one year)
    16
  • District of Registration*full name
    17
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