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AVMC ALUMNI ASSOCIATION
AVMC ALUMNI ASSOCIATION LIFE TIME MEMBERSHIP FORM
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ONLINE REGISTRATION FORM
Fill this registration form including details of payment. Your membership confirmation will be sent to you within a week .
Option 2
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1. NAME OF THE ALMUNUS ( Type in Block Letters)
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Your answer
2. GENDER
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Your answer
3. DATE OF BIRTH
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MM
/
DD
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YYYY
4. BATCH YEAR *Year of Admission MBBS /PG
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5. YEAR OF COURSE COMPLETION
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6.ADDRESS FOR COMMUNICATION
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7. PERMANENT ADDRESS
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8. MOBILE NUMBER
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9. EMAIL ID
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10. HIGHER EDUCATION DETAILS -WITH NAME OF COLLEGE, UNIVERSITY AND ADDRESS.
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11. CURRENT PLACEMENT WITH COMPLETE ADDRESS
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12. ACHIEVEMENTS -AWARDS, MEDALS IF ANY IN DETAILS
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13. PAYMENT DETAILS FOR LIFE TIME MEMBERSHIP RS.2000/-
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ONLINE PAYMENT -KOTAK MAHINDRA BANK , ACCOUNT NUMBER-5712791604, IFSC CODEKKBK0008955
CHEQUE/DD FAVOUR OF AVMC ALUMNI PAYABLE AT PONDICHERRY.
DIRECT CASH - PLEASE FILL THE FORM AND ADD DATE OF PAYMENT AND RECEIPT NUMBER
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14. DETAILS OF DIRECT CASH / DD/ CHEQUE PAYMENT
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15. Passport Photograph
Option 1
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16. ANY QUERY PLEASE CONTACT
DR.G.K.POONGOTHAI -9003404531
DR.S.NARAYANASAMY- 8940811352, 8248750702
DR. T. PRASAD -9843146656
Other:
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17. ALUMNUS FEEDBACK
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