T.N. Medical College Past-Students' Society


Kindly print* the Membership Form below, fill it up & send it along with the Membership Fees by Cash / Cheque to the following address:

Dr. S.N. Rao, Dept. of Pharmacology, T.N. Medical College,
Dr. A.L. Nair Road, Mumbai - 400 008. INDIA

* To print kindly click within the text area of the form & click on "File/Print - Only the Selected Frame" or "File/Print Frame", depending whether you are using the Internet Explorer or Netscape Communicator Browser.

T. N. MEDICAL COLLEGE  
Past Students' Society  
Membership Form  
For Office Use
Memb. No. : _____________
Date : _____________
Amount Rs. : _____________

MEMBERSHIP FORM
Name : ________________________________________________
Sex : Male       Female
Date of Birth : ________________________________________________
Residential Address : ________________________________________________
  ________________________________________________
  ________________________________________________
Telephone (Res.) : ________________________________________________
Clinic / Consulting
Room Address		 : ________________________________________________
  ________________________________________________
  ________________________________________________
Telephone : ________________________________________________
Fax : ________________________________________________
Email : ________________________________________________
Yr. of joining TNMC : ________________________________________________
Qualifications : ________________________________________________
Any other Info. : ________________________________________________
Blood Group : ________________________________________________
Type of Memb. : Life       Patron

I hereby request you admit me as a Life Member / Patron of the T.N.M.C. Past Students' Society. I am enclosing a sum of Rs. _____________ (Rupees ________________________________________________) by Cash / Cheque No. _____________ dated _____________ drawn on ________________________________________________.


Signature ________________________
Date        ________________________

P.S.  

  •  
    		•
    Cheques may be drawn in favour of "Topiwala National Medical College Past Students' Society" and marked account payee.
  •  
    		•  Outstation cheques should include Rs. 5/- towards bank charge.
  •  
    		•  Life Membership of Rs. 250/- and PATRON Rs. 1000/-.
    ----------------------------------------------------------------------------

    Received with thanks from the secretary:

    (1) Original Membership Receipt
    (2) Identity Card     		Membership No.: _____________



    Signature of Member



    Back to TNMC Past-Students' Society