Global HealthCare

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	Corporate Members

	Individual Members

	Application Form

Membership No.
Patient No.

Membership Application Form

Corporate

Individual

Membership Plan:

Total Membership Fee:

Title

Last(Family)Name

First

Middle

中文

Date of Birth:

(dd/MM/yy)

Gender:

Male

Female

Nationality:

Passport No:

Blood Type:

Address:

Postal Code:

Country:

Phone:

(Home)

(Office)

(Mobile)

Company Name:

Fax:

Email:

Religion:

Insurance Company:

Evacuation Company:

Signature of Applicant:

Date:

Payment Method

Cash

Visa

Mastercard

American Express

Diners

JCB

Union Pay

Transfer to a/c*

*Account Information
Company Name: Global HealthCare Shanghai Ltd.
Bank Name: JingAn Sub-Branch, Shanghai Branch, Bank of China
Account Name: Global HealthCare Shanghai Ltd.
Account Number:
USD payment – 044133-8900-12969808091014
RMB payment – 044133-8900-12969808093001

Please note that membership is effective upon receipt of payment.

	For cash payment, please pay to cashier.
	For credit card payment, please attach a copy of your credit card front & back. Please make sure the credit card is registered in your name, with your signature and is valid for at least three months.