Association Enrolment Form

(W.B.E.M.C) COLLEGE ASSOCIATION ENROLMENT FORM

Application for recognizing study Centre / permission to start course / courses or increasing intake of students under council. Development of Indian society.
Attached annexure where ever essential new / old college Submit the information detail to the Council office within one month after received the date of issue.

Registration No :

Full Name :

Son. / Daughter. / Wife of :

Mother Name :

Sex :

Date of Birth :

Village / Word :

P.O :

P.S :

DIST :

State :

Pin No :

Age :

WhatsApp No :

Gurdian Contact No :

Emergency Contact No :

Category/Caste :

Religion :

Nationality :

Aadhaar/Voter Card No :

Medical Qualification :

Blood Group :

Email :

Student Registration No :

Date of Registration :

Date of Application :

2. Clinic/Practice Details (Clinic Name & Address)

Clinic Name :

Trade Licence No :

Village / Ward:

P.O :

P.S :

DIST :

State :

Pin :

Application Fee: 1,000/--

Signature of Applicant :