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Form of Application for Admission as a Life member of the Grace Medical Mission
Name (in block letters)
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Address (in block letters)
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Zip Code/Pin Code
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Email
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Age
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Sex
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General Education
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Present Occupation
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Scheme of Payment Chosen
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Amount of fee sent by M.O/Draft/I.P.O
Including the Registration Fee Rs. 25
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Agreement
I solemnly agree on my word 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
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Date
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Space for Office Use
Ref. No:
Proposed by:
Seconded by:
Remarks:
Secretary
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