SILCHAR MEDICAL COLLEGE ALUMNI ASSOCIATION

SILCHAR : : ASSAM

Life Membership No…………………

Date…………………………………...

SURNAME                                                                FIRST NAME

NAME……………………………………………………………………………………………………………...

(in block letter)

ADDRESS…………………………………………………………………………………………………………

(in block letter)

                     ………………………………………………………………………………………………………..

                     State…………………………………………………Pin Code……………………………………

Date of Passing MBBS/PG(Degree/Diploma) from SMC…………………………………………………….

DECLARATION BY APPLICANT: I declare that the above details are correct. I shall abide by the Rules & Regulations of the Association in force and any subsequent amendments made from time to time.

                     I am enclosing Cash/Bank Draft No……………………………………………………………… on……………………………Bank Dated…………………… for Rs.2000/- (Rupees Two thousand) only Dated………………………. As Life Membership Fees.

                                                                                                            Signature

 SPECIMEN SIGNATURE

OF APPLICANT

                         1……………………………………….. 2……………………………………….

*        Bank Draft should be in favour of “SILCHAR MEDICAL COLLEGE ALUMNI ASSOCIATION” payable at “SILCHAR”.

*        Application for life membership along with Cash/Bank Draft for the subscription should be addressed to Dr.Aniruddha Biswas, Ambicapatty, Silchar-788 004.