Silver Jubilee Celebrations, Govt.Medical College, Kota

Registration form (Off-line)

1. Registration Category:

¯Category Tick (P) the appropriate box¯
i) / Faculty of GMC, Kota (Sr. Professor, Professor & Assoc. Professor)
ii) / Faculty of GMC, Kota (Assistant Professor & Sr. Demonstrator)
iii) / Alumni (Batch 1992 – 2010)
iv) / P.G./Locum/Senior Resident (non-alumni; working in this Institution)
v) / Alumni/students (Batch 2011 – 2017)
vi) / M.O./Non-teaching doctors (non-alumni; working in this Institution & Associated Hospitals)

2. Registration Sub-category {Tick (P) the appropriate box}:

i) / Single
ii) / with family

3. Title {Tick (P) the appropriate box}:

i) / Mr
ii) / Mrs
iii) / Ms

4. Name:

First Name / Middle Name / Last Name

5. Date of Birth:

Date (DD) / Month (MM) / Year (YYYY)

6. Batch

MBBS Admission Year / Name of College / PG Admission Year / Name of College

7. Mobile No.: ______

8. Email i.d.: ______

9. Present Status: ______

______

10. Family details:

Name / Relation / Age
(in yrs) / Whether accompanying in fest / If family member is an alumni of GMC Kota then Batch

11. Achievements:

During MBBS / After MBBS

12. Mode of Payment {Tick (P) the appropriate box}::

Cash / D.D. / Cheque / Online / IMPS / Net Bank / RTGS / NEFT

(Plz enclose photocopy of document in confirmation of your claim of deposition of registration fee)

13. pics:

Signature of Participant

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Registration fee:

Early Bird upto 31.10.17 / After 31.10.17 registration
For Family / For Single / For Family / For Single
Faculty of GMC, Kota (Sr. Professor, Professor & Assoc. Professor) / C 10,000/- / ------/ C 12,000/- / ------
Faculty of GMC, Kota (Assistant Professor & Sr. Demonstrator) / C 6,000/- / ------/ C 8,000/- / ------
Alumni (batch 1992 – 2010) / C 10,000/- / C 7,000/- / C 12,000/- / C 9,000/-
P.G. /Locum/Senior Resident (non-alumni; working in this Institution) / C 6,000/- / C 4,000/- / C 8,000/- / C 6,000/-
Alumni/students (Batch 2011 – 2017) / ------/ C 2,000/- / ------/ C 2,500/-
M.O./Non-teaching doctors (non-alumni; working in this Institution & Associated Hospitals) / C 6,000/- / C 4,000/- / C 8,000/- / C 6,000/-