Sinhgad Technical Education Society's
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

    1.   Name
    2.   Date of birth (yyyy-mm-dd) Select Date
    3.   Gender
    4.   Present Communication Address
    5.   Permanent communication address
    6.   City
    7.   State
    8.   Pincode
    9.   Country
    10.   Mobile No.
    11.   Email Id
    12.   Adhar No.
    13.   PAN Card No.
    14.   Duration spent in SKNMC&GH as: MBBS student/Intern/PG student/Faculty:         Years

For Alumni Students (MBBS/Intern/PG student)

    1.   Year of Admission at SKNMC
    2.   Currently studying in     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 For office use only
    Patron member/Donor member/ Life member/Affiliate Life member/Graduate Associate member/Student member/ Honorary member
    Amount paid
    Mode of payment (NEFT/Cash/Cheque/DD):


(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.