KGPMTA Membership Registration Form

Unit

Name

Designation

Gender

Date of Birth

Mobile

Email

Marital Status

Name of Spouse

Occupation of Spouse

Office Address

Residential Address

Date of Service Entry

Date of Regularisation

Details of Post

Post Held	From	To

Academic Details

Course	College	University	Year

Bank Account Details:
Name: KGPMTA
Account Number: 67122806323
IFSC: SBIN0070111
Branch: Medical College, Kottayam