IMAP Inc.

IMAP Membership Form

Personal information

Lastname

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Firstname

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Middlename

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Address

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Contact Number

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PRC Number

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Date of Registration

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Expiration

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Instititution information

Government Institution Information

Place of Employment

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Clinic Name

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Address

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Position in the Clinic

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Type

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Number of Years Employed

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Private Institution Information

Place of Employment

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Clinic Name

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Address

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Position in the Clinic

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Type

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Number of Years Employed

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Family Planning & Maternal and Child Health Trainings

FP-CBT LEVEL 1

FP-CBT LEVEL 2

PPFP/PPIUD

BEMONC TRAINING

EINC

NEWBORN SCREENING

FHSIS

USAPAN SERIES

PSI TRAINING

Others (Please Specify)

Proof of Payment

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Membership Fee is 500 pesos and below are the modes of payment that you could use:

#	Options	Name	Account/Mobile
1	Bank Name: Metrobank	Account Name: IMAP, Inc	Account #: 067-7-06751139-1
2	Mode: Palawan Express/MLhuillier	Name of Receiver: Aileen Mae De los Santos	Mobile No.: 0915-573-2762
3	Mode: GCASH	Name of Receiver: Aileen Mae De los Santos	Mobile No.: 0915-573-2762

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IMAP Membership Form

Personal information

Instititution information

Government Institution Information

Private Institution Information

Family Planning & Maternal and Child Health Trainings

Proof of Payment

OUR MISSION

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