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Please print out this form, fill it up and send it to us.
GOSUMEC ALUMNI
ASSOCIATION
SETH G. S. MEDICAL COLLEGE, PAREL, BOMBAY 400012.
Application for Membership
Date:
To,
The President,
Gosumec Alumni
Association,
Dean's Office,
Seth G. S. Medical College,
Parel,
Bombay-400012.
Sir,
I graduated from Seth G.S. Medical College in 19__.I wish to enroll myself as Patron / Life Member of the Gosumec Alumni Association. I am sending herewith cash / cheque for Rs.____ as Patron Membership / Life Membership fee.
My personal data is as follows:
Name :
Professional address:
Tel. No.:
Fax:
E-mail.:Residential address:
Any other information:
Sincerely
yours,
(Signature)
Membership fee : Patron membership: Rs. 2500/- Life membership: Rs. 500/-
For NRls: US$ 200
Cheques should
be in favour of "Gosumec Alumni Association".