Centre of Social
Medicine and Community Health ALUMNUS CELL Registration
Form
Kindly paste your recent photograph here
Name: Date of Birth: Year of joining Center: Programmes completed: M.Phil. :
M.C.H. / M.P.H.: Ph.D.:
Year of award of degree: M.Phil. :
M.C.H. / M.P.H.:
Ph.D.: Any further qualification:
Certificate / Diploma / Degree
Institution
Year Your Current Address and contact details: Residence: Address: Phone no.:
E-mail: Office: Designation: Address Phone no.:
E-mail: Work experience:
Addresses / e-mail / phone / mobile nos. of other alumni: (please send us as many contacts as you have and also forward this mail to them.) 1] 2] 3] 4] 5]
In case of inaccessibility of internet send the duly filled form on address given below by post. Dr. Ritu Priya
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