Government Dental College , Thiruvananthapuram

GOLDEN JUBILEE CELEBRATIONS
REGISTRATION FORM

Reg. No ...........................................  (for office use)

Name ...............................................

Age ...................

Gender: M/F

Address for communications

Tel. Number : .....................................

Mob...................

E-mail ..........................

Year of Admissio:

BDS .................

MDS .............................

No. of accompanying persons :

Adults ...............

Children .......................,
(Below 12 years)

Payment Details

DD/Cheque/Cash  (No ........................... dated .........................drawn on ............ ... Bank for RS ..........................................( Rupees ..................................................)

Type of Registration (Tick): Platinum Card/Diamond Card/Gold Card/Silver Card/ CDE/Banquet/ Registration only

All payment should be in favor of Secretary, Golden Jubilee Celebrations, GDC, Thiruvananthapuram payable at Thiruvananthapuram)

Do you like to buy a book for the Library? If yes, details:

Purchased book can be mailed to

Dr. Sreelal,
Organizing Secretary,
Golden Jubille Celebrations,
Govt. Dental College,
Thiruvananthapuram, 695012.
E-mail: This e-mail address is being protected from spambots. You need JavaScript enabled to view it This e-mail address is being protected from spambots. You need JavaScript enabled to view it