1) Name of the organization:
2) Registration number and year:
3) Full postal address:
4) Telephone no(s):
Fax no(s):
4) E-mail:
6) Name of the chief functionary of the organization:
7) Name and designation of contact person in relation to medical supplies from CDMU:
8) Details of location to enable CDMU’s delivery team to reach easily (if relevant):
9) Areas of activity:
10) Type of healthcare provided:
11) Other information:

Population covered :
Category of population covered :
Number of staff
Medical staff
Health workers
Yearly medicine expenditure :
Yearly medicine budget :

12) In your health program do you have the following:
13) Do you require help from CDMU in conducting research work:
14) Do you want to participate in training program conducted by CDMU:
15) Do you want to participate in advocacy program conducted by CDMU:
Full name of the applicant
Signature with Date:

This membership is a formal requirement of Community Development Medicinal Unit [CDMU] before it can provide service to any not-for-profit organizations, who are registered with the Register of Societies or have other legal status. The membership is available on submission of this application form along with the nominal lifetime Registration Fee of Indian Rs. 500/- [rupees five hundred only], subject to acceptance of the application form by CDMU Executive Committee. You are requested to fill up this form and submit it along with the membership fee by Cash / Demand Draft / Bank transfer* in favor of ‘Community Development Medicinal Unit’. The following documents needs to be attached with the application form:

Photocopy of your Society Registration Certificate
Photocopy / Declaration of 80 G registration certificate
Latest annual report
Photocopy / Declaration of 12 A registration certificate
Balance sheet [Optional]
Photocopy of memorandum of association

Bank details: Community development medicinal unit.
Current A/C no. 34185332523
State bank of India, Entally branch
IFS code SBIN0001830
Bank Address: 24, girish Chandra Bose road, entally
Kolkata 700014 ph no. 033 22846290