INDIAN ... - Patliputra Medical College Dhanbad Alumni Association by hedongchenchen

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									         PATLIPUTRA MEDICAL COLLEGE ALUMNI ASSOCIATION
     ALUMNI MEET 2010 Palika Services Officer's Institute, Vinay Marg, Nehru Park (Near Ashoka Hotel) New Delhi
                                          REGISTRATION FORM

Name: ……………………………………………………………………………………………………………………….
              (Surname)  (First Name)  (Middle Name)

Admission Batch at PMC Dhanbad: ………………………………………………………………………………………....

Communication Address:


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

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

…………………………………………………………………………………………………………………………….
Mobile                       Email

              Career Highlights                      College/ University                                 Year




Working at




          *For adequate arrangement at the event:
           Family Details*                               Relationship                                     Age




Place:                                                                        ______________________
Date :                                                                        (Signature of the Applicant)

Post only by speed post/ currier to Dr Raman Kumar B-32 Chanakya Place Part 1 (Opp C-1 Janakpuri) Uttam Nagar New Delhi 10059 India.

Please also send a soft copy of this form duly filled to dr_raman@hotmail.com for appropriate arrangements at the alumni meet.
………………………………………………………………………………………………………………..
Reciept

Received Rs …………………….for registration at PMC Alumni Meet 2010 31st March , from Dr…………………………
Batch………………..in Cash or Cheque/ Draft No…………………... dated ……………………………………………….



Authorized Signatory
Registration Fee


Category of Registration
Single (working/ Practicing)        1000//-
Family(Spouse & children)           1800/-
PG Aspirants                        800/-
Current students of PMC Dhanbad     500/-
                                    Free             Couple (Both husband & wife from PMC Dhanbad) – 2000/ -
Faculty of PMC)- Retired/ working

The Registration fee should be paid either by cash or crossed bank draft/ cheque in favor of “ Rakesh Kumar Ac No.602810310000500
Bank of India, Chittranjan park branch” payable at New Delhi. You may also transfer the amount electronically. Surplus funds
following the event shall be transferred to a dedicated bank account in name of a registered society (Alumni association).

								
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