4310 English Morning Lane, Ellicott City, MD,21043 Tel.: (410) 418-8740, Fax. (410) 720-2545
President
Amarjot S. Narula, MD
Ridgewood, NJ
Secretary-Treasurer
Kulwant S. Modi, MD
Ellicott City, MD
Members-at-Large
Baljinder S. Bathla ,MD
Chicago,IL
Tejinder S. Glamour,MD
Seminole, FL
Maninder S. Gujral, MD
Albany, NY
Varinder S. Rathore ,MD
New York, NY
Sartaz S. Sibia, DO
Boca Raton, FL
Dental Liaison
Manbir K. Pannu, DDS
Hinckley, OH
Entertainment Director
Amarjit S. Nijjar, MD
Shreveport, LA
CME Directors
Amarjit Singh, MD
Buffalo, NY
Harjit S. Bajaj, MD
Ellicott City, MD
Executive Secretary
Parminder K. Dhillon
Raleigh, NC
Past President
Mohan Deep S. Dhillon, MD
Binghamton, NY
Email:
Website :
Membership Application
Name: ______D.O.B.______
Name of spouse______Profession______
Email______
Address______
City______State______Zip______
Phone
Home______Work______
Cell______Fax______
School of Graduation______Year______
Prof Degree: M.B.B.S., M.D., D.O., D.D.S., B.D.S. Circle one
Profession______Specialty______
Category of Membership: Please circle one and include correct dues
1) Active Member :$ 100.00
2) Active Associates Member (Resident): $25.00
3) Honorary Member (Retired Physicians and Medical/Dental Students): No Fee
4) Auxiliary Member (Spouse): No Fee
5) Life Member : a) $ 1000.00 regular fee.
b)$ 750 .00 years 4-5 after completion of training.
c) $500.00 years 0-3 after completion of training.
Children
1)______M / F2)______M /F
3)______M /F4)______M /F
Pledge: I ______, hereby solemnlyaffirm that I am a Sikh, that I believe in the Guru Granth Sahib, that I believe in the Ten Gurus. I pledge to abide by the Constitution and bylaws of the “North American Sikh Medical and Dental Association”. I also pledge to promote the goals of the organization to the best of my ability.
SIGNED: ______Date:______
Please send your check or money order payable in US funds to NASMDA at the following address .
Kulwant S. Modi ,MD
4310 English Morning Lane
Ellicott City,MD 21043
4310 English Morning Lane, Ellicott City, MD,21043 Tel.: (410) 418-8740, Fax. (410) 720-2545