National Association of PLHA in Nepal

(NAP+N)

Online Membership Form

Name:

Permanent Address:

Temporary Address:

Mailing Address:

Phone No: Office / House:

E-Mail:

Academic Qualification:

Date Of Birth:

Age:

Sex:

Marital Status: Married Unmarried Devorced

Number Of Children: Son Daughter

Hiv Status: Infected Non-Infected

Infected Year:

Year of HIV Suspect:

Taking ARV or Not: Yes No

If yes then from where:

Affiliated with any organization: Yes No

Have experienced in HIV feild: Yes No

I agreed with above mentioned terms and conditions that from my own knowledge, from the date I associated with this organization. I will obey all the rules and regulation of organization.

Member’s Name:

Witness:

Date:

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National Association of PLHA in Nepal
( NAP+N )
Makhmali marg - 26, Marajgunj,Chakrapath, Kathmandu, Nepal
Tel.No. +977- 1 - 4373910 , P.O.Box: 8975, EPC: 4112
E-mail: napn@napn.org.np
Website: www.napn.org.np