Application Form

APPLICATION FORM [ MARC]

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APPLICATION FORM

 

AVICENNA  RESEARCH CENTRE FOR UNANI  MEDCINE                                                                                                                  

 

  MUMBAI - INDIA

 

 

 

  APPLICATION   FORM   FOR  MEMBERSHIP (M.A.R.C. )

 

 

 

1. NAME: _________________________________________

 

2. DATE OF BIRTH :_______________SEX: MALE/ FEMALE

 

3. QUALIFICATION :________________________________

 

4. ADDRESS : _____________________________________

 

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____________________________________________________

 

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____________________________PIN:________________________

 

 

 

5. PHONE NO: (IF ANY): _______________________________

 

6. E.MAIL (IF ANY): __________________________________

 

7. Here , I am sending Membership Fees Rs: __________ by cash / Money Order / Bank Draft  , today . ( Bank Draft must be in favour of AVICENNA  RESEARCH  PUBLICATION   and should be payable at Mumbai. ) I will abide all Rules & Regulations of Avicenna Research Centre for Unani Medicine , Mumbai.

 

 

 

Date :                  

 

                                                                      SIGNATURE