AtutBandhan

Registration Form For Sponsor

(A.) Personal Information: *

1.Name: *

2.DOB: *

3.Father/Spouse Name: *

4.Gender: *

5.Profession: *

6.Contact No.: *

7.Email: *

8.Upload Aadhar: *

(B.) Address: *

(i). Present Address

State: *

District: *

Block: *

Police Station: *

Post Office: *

Area/Locality: *

House No/Street: *

PinCode: *

(ii). Permanent Address same as permanent address

State: *

District: *

Block: *

Police Station: *

Post Office: *

Area/Locality: *

House No/Street: *

PinCode: *

(C.) Information regarding sponsorship*

1.Number of medical student willing to sponsor: *

(D.) Company Details: (If the sponsor is a Company):*

3.If Company/Trust is sponsoring: *

1.Company Name: *

2.Register office location & address: *

3.Position held by sponsor in company: *

Willingness to Sponsor/Support Medical College Students From Poor and Deprieved Households *

I (we) hereby undertake to support / sponsor above number of poor meritorious student of Government Medical College of Odisha for his/her/their entire/balance MBBS Course under the ATUT BANDHAN Initiative.

Date: *

Place: *

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Registration Form For Sponsor

(i). Present Address

(ii). Permanent Address same as permanent address

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