Washington Association of

Physicians of Indian Origin

Executive Office – Ms. Heena Ajudia

2637 SW 172^ndStreet, Seattle, WA 98166

www.wapiusa.org

WAPI appreciate very much for referring a colleague, new comer or a friend to WAPI. Your support thru referrals will strengthen our organization for years to come. Please provide information as much as you feel comfortable. WAPI will add this information in its database to provide ongoing news about WAPI events etc to all colleagues and friends in its database.

>>>>>>Thank You For Your Referral<<<<<<<

Colleague/New Comer’s Name:	#1	#2
Gender :
His/Her Mailing Address:
Home Phone:
Home Fax:
Mobile Phone:
Email Address1:
Email Address2:
Speciality:
Medical School:
Graduation Year:
(Thank You For Your Referral) Your Name:
Your Email Address for Us to Thank You:

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