Member Apply Form

BUXAR HEALTH ORGANISATION

Member Apply Form

Name * :

Gender * :

Date of Birth * :

Profession:

Blood Group *:

State * :

District *:

Mobile No. *:

Aadhar No. *:

Address *:

Pin Code *:

Email:

Profile Picture:

Upload

Other Document

Upload

Health Card Fee - 99/- Family Card Fee - 599/-

Bank Detail -

Bank Name - HDFC BANK LTD
Account Holder: Buxar Health Organisation
Account No : 50100685690302
IFSC: HDFC0001652
Account Branch: BUXAR

UPI SCAN:

Payment Mode *:

Payment Receipt Upload:

Upload