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Vidarbha
Ophthalmic Society

9822693404

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Chinchole Eye Hospital & Eye Bank Buldhana - 443301

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Chincholehospital1@gmail.com

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Membership Form

Vidarbha Ophthalmic Society

Membership Form

To be filled in BLOCK Letters with BLACK INK

Membership Form
Gender:

Addresses

Declearation

I hereby declare that the above details are correct and I wish to be a Life member of the Vidarbha
Ophthalmic Society. I have read and understood the instructions overleaf. I shall abide by the Rules,
Regulations and By--laws of the Society as in force and any subsequent amendment(s) made from time to time.

Please find herewith enclosed Rs.___________(in words _______________________________________________,) by cash / cheque / DD (no.:_____________________________________), dated _____________________, drawn on ____________________________.

_____________________________
Applicant Signature

_____________________________
Name