AtutBandhan

Registration Form For Sponsor

(A.) Personal Information

Name *

DOB *

Father/Spouse Name *

Gender *

Profession *

Contact No. *

Email *

Upload Aadhaar *

(B.) Address

Permanent Address *

State *

District *

Block *

Police Station *

Post Office *

Area/Locality *

House No/Street *

Pincode *

Present Address * Tick if same as Permanent Address

State *

District *

Block *

Police Station *

Post Office *

Area/Locality *

House No/Street *

Pincode *

(C.) Information regarding sponsorship*

Number of medical student willing to sponsor

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

If Company/Trust is sponsoring *

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

Sl No	Student Name	MBBS Batch
1	Rahul Kumar	2015
2	Priya Das	2015
3	Amit Sahoo	2015