Data Collection Form For All Alumni (October 23,1998)

Guntur Medical College Alumni of North America

Even though you may have submitted this information in the past, please do complete the form below to generate comprehensive information about the alumni. If your address, area code of phone number and email address or any other information please enter your both last and first name and the changed information.
Spouses who are also the alumni of GMC please complete the form separately. If you fill and send this form completely you do not need to fill and send the Membership information that has been sent along with the newsletters and Alumni directory.

Please do not use the "Enter" or "Return" key on the keyboard. If you do, it will prematurely submit your data.
Please use "Tab" key or the mouse to navigate between the form fields.

For USA & Canada Alumni ONLY. If from other countries, please click here to send the data by email.

Last Name:
First Name:
Year of joining GMC:
Main Specialty:
Address1:
Address2:
City:
State:
Country:
Zip:
Home Telephone:
Office Telephone:
Fax Number:
Email:
Spouse's name:
Occupation:
If from GMC, the year of joining:

Children's First names and ages:

Comments:

My Membership Status is:

Not a Member Life Member Member In Training In US-Preparing for Training

If you are not a member, please consider becoming a life member. Your contribution is tax deductible and helps the alumni and GMC in various ways.

Life Membership: $ 250
Member-in-Training: No fee

Please make check payable to GMCANA and mail to:

Treasurer: Babu Reddy Sagireddy (83)
4026 Pine Lake Circle, Stockton, CA 95219
209-546-1868, BabuReddy@gmcana.org

Form revised Thursday, July 03, 2008

Name of the Child

Date of Birth

Marital Status

Education

Career Goals

MaleFemale

MaleFemale

MaleFemale

MaleFemale

MaleFemale