GOLDEN JUBILEE - 2012
Mymensingh Medical College (MMC) Registration Form
Registration No. ( ( To be filled by the office ) All sections should be filled by the Alumni / Student.
1. Name in Full (Block Letter): _______________________________________ Nick name: ____________________
2. Date of Birth (day / month / year): ___ /_____ / _____ 3. Sex: Male / Female (Put a Tick √ Mark) 4. Batch – M ______ Year of Graduation ____________ 5. Present professional position with Address : ________
___________________________________________________________________________________________
6. Mailing Address :_______________________________________________________________________________
_____________________________________________________________________________________________
E-mail : __________________________________ Phone : Mob - ____________________________________
Res : ____________________ Off : ______________________ Fax : _________________________________
Family : Spouse:______________________________________ Occupation : ______________________
Son/Daughter: ____________________________ Son/Daughter: ___________________________
Son/Daughter: ____________________________ Son/Daughter: ___________________________
7. Please put tick ( √ ) mark on the following registration fee for Accompanying person : Self Tk 2000/-
**
Spouse Tk 1000/- Child > 12 years Tk 500/- (500 X ) =Child < 12 years Tk 300/- (300 X ) = Internee 1000/- Student Tk 200/-
Total: Tk ……….………… In wards Taka ……….………received
In Cash / Cheque No………Bank………Date: ……….
**
If spouse is Ex-MMC student, Please fill up separate Registration form.8. Please put tick (√) mark If you need Accommodation (Self paid). Specify for how many Person ...
& Please Fill-up Accommodation Form. Contact email: [email protected].
________________________________ ____________________________
Signature with date (Participant) Signature with date (Recipient). M - Name: Name:
- - - Golden Jubilee-2012 /
PARTICIPANT COPY
Registration No. ( To be filled by the office )
Received Tk- . . . (In wards Taka . . . . . . .)
from Dr./ Student……….Batch M - ……… In cash / Cheque No.
………. Bank……… Date: ………. with thanks.
Received by: _________________________________
Signature with Name & date (Recipient) M -
NB : LAST DATE OF REGISTRATION: 15 / 01 / 2012 ( WITH 10% LATE FEE 31/01/2012 ) For Accommodation please contact through E-mail: [email protected] (Self Paid).
Please attach Two recent passport size
photographs of Alumni /
student M
M
id2948468 pdfMachine by Broadgun Software - a great PDF writer! - a great PDF creator! - http://www.pdfmachine.com http://www.broadgun.com
