Name .............................................................................
(Block letters with initial)
Age..........................................................................
Permanent Address.............................................................................
Block Letters).....................................................................................
PIN/Zip Code :................. Tel.No.......................................
MBBS Batch No......... Year .......... College.......................................
House Surgeoncy / SHS ....Year ............. College...............................
Post Graduate Degree / Diploma ..Year....... College............................
Present Position......................................................................
Family Status .... Married / Unmarried .......No. of Children.................
Outstanding Achievement.........................................................
(Curricular or Extra Curricular .................................................
Prizes, Medals etc.)..................................................................
I...........................................................hereby undertake to abide by the Rules and Regulations of the Association.
Place :........................ Signature :........................
Date :......................... Name :.............................
Note : The Life Membership fee is Re. 250/- for Alumni residing in India.
For Alumni settled abroad the Life Membership Fee is US $ 100. This may be paid in cash, by MO,DD or Cheque drawn in favour of 'ALUMNI ASSOCIATION, CALICUT MEDICAL COLLEGE'. An amount of Rs. 20/- may be added for outsation cheques. Completed application is to be sent to the secretary.
Two Passport size Photographs may be sent with the Application, one of them is to be fixed on the Identity Card.
FOR OFFICE USE
Mode of Payment : Cash/MO/DD/Cheque No................Bank.................
Receipt No....................... Alumni No................................
Address Book Entered............. A/c Book Entered.........................
IC & Receipt Despatched on.................................................
Treasurer.........................Secretary................................
Please Print this Application Form and use it for application.
Mailing Address :
The Secretary, Calicut Medical College Alumni Association, Medical College P.O.,Calicut-673008,India.
Email: medalumn@md2.vsnl.net.in
