BMC Alumni Association

Application Form

First Name        :                                 Surname           :

Date of Birth     :

Address1          :

Address2          :

City              :                             Pin               :

Country           :

Business Tel      :                             Business Fax      :

Home Phone        :                             Home Fax          :

Mobile Phone       :                             Pager             :

E-Mail            :                             Year of passing MB:

PG Qualification    :                            Specialty         :

Institution       :                              Designation       :

Mode of Payment   : Cheque / DD

Chq / DD No.      :

Bank              :

DD Date           :

Amount            :

Signature (Not needed for online submission)

(Life Membership fee    : Rs. 1000=00 for residents of India  USD 50=00 or 25 Pounds Sterling equivalent for NRIs. Cheques made Payable to 'Bangalore Medical College, Alumni Association')

  Donors to the Building Fund automatically become members of the association

                Form can be submitted by emailing to lakshman@58family.net