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Form of Application For Admission

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FORM OF APPLICATION FOR ADMISSION

As a Life member of the Grace Medical Mission

1. Name (in block letters) ----------------------------------------------------------


2. Address (in block letters) ----------------------------------------------------------
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Pin Code ---------------------------------
3. Age --------------------------------------------------------
4. Sex --------------------------------------------------------
5. General Education ---------------------------------------------------------
6. Present Occupation ---------------------------------------------------------
7. Email ---------------------------------------------------------
8. Mobile No. ---------------------------------------------------------
9. Scheme of payment chosen ---------------------------------------------------------
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10. Amount of fee sent by M.O/ DD/ I.P.O/ NEFT
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AGREEMENT
I solemnly agree on my world of honour, that I shall not expose the postal Lectures to
anyone, and I hereby declare that from the day I commence my study I shall consider
myself morally bound to advance the cause of the Grace Medical Mission as set forth in
the Prospectus.

Place --------------------------
Date --------------------------
Signature
________________________________________________________________________
Space for Office Use

Ref. No:
Proposed by:
Seconded by:
Remarks:
Secretary

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