Smt. Kashibai Navale Medical College and General Hospital

ALUMNI ASSOCIATION OF SMT. KASHIBAI NAVALE MEDICAL COLLEGE & GENERAL HOSPITAL, PUNE

APPLICATION FOR MEMBERSHIP

Personal Current Details

Name *

Date of Birth

Gender:

Male

Female

Present Communication Address

Permanent communication address

City *

Pin code

State *

Country *

Mobile *

Email *

Aadhar No.

PAN Card No.

Duration spent in SKNMC&GH as: MBBS student/Intern/PG student/Faculty: *

For Alumni Students (MBBS/Intern/PG student)

1. Year of Admission at SKNMC

2. Currently studying in which Year

Semester

3. Passing Final MBBS (Month & Year)

4. Date of Internship completion

5. Are you pursuing Post-graduation/ Completed Post-graduation

If Yes give details:

Name of the Course

Institute where PG course is being pursued

Year of Admission

Subject of specialization

Date/likely date of Completion of PG course

For Faculty

1. Date of joining the institute

2. Designation

3. Department

Payment details: (for office use only)

Category of membership

Patron member / Donor member / Life member / Affiliate Life member / Graduate Associate member / Student member / Honorary member

For office use only (Membership)

Amount paid

Mode of payment (NEFT / Cash / Cheque / DD)

Captcha Image

91683

Type the code you see in the image

(Cheque/DD drawn in favor of: "Alumni Association of Smt. Kashibai Navale Medical College & General Hospital"

Bank details:
Account name: Alumni Association of Smt. Kashibai Navale Medical College & General Hospital
Account No:025120100000 211
Bank name: The Thane Janata Sahakari Bank Ltd
Branch: Pune Ext Counter 2, Narhe
IFSC code: TJSB0000025
Account type: Current

Note:
1. Form should only be submitted online
2. Hard copy should not be sent.
3. Mere submission of form does not guarantee membership of “ALUMNI ASSOCIATION OF SMT. KASHIBAI NAVALE MEDICAL COLLEGE & GENERAL HOSPITAL, PUNE”.
4. The Alumni association reserves complete rights of admission.
5. Membership shall be confirmed only on receipt of membership fees.