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 ____________________________.