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AHCS Beneficiary Membership Application

Apply for lifetime Beneficiary Membership of Assam Healthcare Cooperative Society. The membership fee is ₹500. Your application will remain pending until our staff verifies your details and payment.

Beneficiary

Beneficiary *

Beneficiary - ₨ 500.00

Total Amount

Members

Prefix *

First Name *

Middle Name

Last Name *

Passport Photo *

Birth Date *

Email (Primary) *

Phone

House No & Street *

City, Town or Village *

Postal Code *

State *

Proof of Payment

Collection or Delivery *

Collect from AHCS office

Deliver to my address

Payment Options

[x] I will pay offline, or have already paid and am awaiting verification.

AHCS Beneficiary Membership Application

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