DISTRICT PROFORMA FOR REGISTRATION- VELLORE DISTRICT

TAMILNADU GOVT. DOCTORS ASSOCIATION

DISTRICT PROFORMA FOR REGISTRATION- VELLORE DISTRICT

(PLEASE USE CAPITAL LETTERS)

AFFIX COLOUR PASSPORT SIZE PHOTO

I.PERSONAL DETAILS

1. NAME;

2. GENDER & DATE OF BIRTH;

4. RESIDENTIAL ADDRESS;

Door no & Street;

Area;

Post; Taluk;

District; Pincode;

Phone no with STD code; Mobile;

Fax; E mail id;

II SERVICE DETAILS

1. DATE OF JOINING SERVICE & 10A1/TNPSC;

2. DESIGNATION & PRESENT INSTITUTION ADDRESS;

Door no & Street;

Area;

Post; Taluk; District;

Pincode; STD&Phone;

Fax; E mail id;

3. TNPSC RANK NO / YEAR (YYYY);

4. CML NO/ 2OO5;

5. SERVICE; DMS / DPH / DME / ESI / OTHERS (mention)

III PROFESSIONAL DETAILS

1. YEAR OF JOINING MBBS & COLLEGE;

2. TN MEDICAL COUNCIL REG. NO;

3. PG / SPECIALITY (DM/Mch) & COLLEGE (IF ANY);

4. PRACTISING SPECIALTY;

IV ASSOCIATION DETAILS

1. NEW MEMBER PAYMENT DETAILS;

2. LIFE MEMBERSHIP NO & DISTRICT JOINED;

3. DATE OF JOINING TNGDA;

4. PREVIOUSLY HELD TNGDA DISTRICT/STATE POST DETAILS;

(Signature of member)