Membership Form

Please fill the form given below to apply for the membership of UPVHA. You will be required to send membership fee and enclosures after you receive a confirmation from us in this regard.

  A. General Information    
  1. Name of the organisation  
  2. Name of the chief executive  
  3. Designation of the chief executive  
  4. Region (Select)  
  5. District (Select)  
  6. Registered Address with PIN code  
  7. Contact address with PIN code  
  8. Telephone(s) no. with STD code  
  9. Fax no. with STD code  
  10. E-mail address  
  11. Website  
  B. Registration Details    
  1. Is your organisation registered? (Select)   Yes
  2. Registered under which act? (Select)  
  3. Registration number  
  4. Date of Registration (Select)  
  5. Is your organisation registered under FCRA (Select)   Yes No
  6. If yes, give FCRA registration no.  
  C. Available Resources    
  1. Human resource  
  a. Trained workers  
  b. Untrained workers  
  c. Paid workers  
  d. Unpaid workers (volunteers)
  
  e. Full time  
  f. Part time  
  g. Male workers  
  h. Female workers  
  2. Physical resources (press control key and click as many options you want to select them)
  
  D. Details of Organisation and Area
  1. Vision, mission and strategy  
  2. Objectives  
  3. Brief introduction of the organisation  
  4. Activities being performed by the organisation (write under heads project name, duration, financial outlay and name of the area)  
  5. Support expected of UPVHA  
  E. Major Problems of the Area
  1. Health  
  2. Social  
  3. Economic  
  4. Others  
  5. Status of community health services in the area
  
  F. References    
    Please give names of two lifetime and/or permanent members as references. We may contact them for checking your credentials.
  1. Organisation 1  
  2. Organisation 2