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 ____________________________.

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Applicant Signature

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Name