Affilation Form – INDIAN RURAL MEDICAL COUNCIL

Institute Affiliation Form

Application Date

Application No.

Course Name

Institute Detail-

Name of the Institute

Address-village/Mohalla

Post

Block

Sub Division

District

State

Email*

Mobile No.

Number Of Employee

Institute (own building or rental)

Personal Detail (Authorised Person) -

Name

Father's Name

Mother's Name

Date of Birth

Gender

Male

Female

Transgender

Category

Permanent Address/Village/Mohalla

Post

Block

Sub Division

District

State

Email*

Mobile No.

Any One ID Details (Aadhar Card, Voter Card, Driving Licence, Ration Card, Bank Passbook, PAN Card, Passport) Number

Educational Qualification (Last Qualification )

Sl No.	Examination	Board/University	Year of Passing	Marks Obtained	Total Marks	Percent of Marks
1

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Declaration

I declare that all the information and statement given by me as above are true and correct. If any information and statement are found to be wrong and false submitted by me at any stage, any disciplinary action can be taken by authority.