Application form for membership in CoMSAA

Application for membership
Colombo Medical School Alumni Association (CoMSAA)

SURNAME (IN BLOCK CAPITALS):……………………………………………………………
OTHER NAMES:…………………………………………………………………………………
ACADEMIC QUALIFICATIONS:……………………………………………………………….
DESIGNATION:………………………………SLMC Registration no.(If available)…………………..
Eligibility for membership (Please complete only the information applicable to you)
Students of the Faculty of Medicine, University of Colombo/ University of Ceylon:         Course of study……………………………………………………………………………
    Year of entry ………………………………………………...............................................
Qualification/s obtained with year/s    …………………………………………………….
Academics of the Faculty of Medicine, University of Colombo/ University of Ceylon:
    Year of employment ……………………………     Designation…………………..
Confirmed in service       Yes / No
Graduates who have contributed to teaching activities of the Colombo Medical College    Years of contribution and capacity………………………………………………….
Graduates who have contributed as administrative / non-academic staff of the Colombo Medical College
Years of contribution and designation..……………………………………………..
Chancellor/ Vice Chancellor of a Sri Lankan University that has a Faculty of Medicine    Years of contribution and designation..……………………………………………..

Contact Details:
………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
Current Address  
(Home)        (Office)



Telephone     Home: ………………  Office: ………………   Mobile: ………………..
E mail address: ………………………………………………………………………….

…………………………..                         ……………………………..
Signature of Applicant     Date

MEMBERSHIP FEE
The subscription for Life Membership is Rs. 5000.00. This is payable by cheque.
Cheques should be written in favour of  COLOMBO MEDICAL SCHOOL ALUMNI ASSOCIATION, account no. 72262672 of Bank of Ceylon, Regent Street Branch.
The cheque/ cheque deposit slip together with the application form should be sent to Prof. Jennifer Perera, Treasurer CoMSAA,  Faculty of Medicine, PO Box 271, Colombo, Sri Lanka.
For internet banking or telegraphic transfer please use the following information(Swift code: BCEYLKLX,  Bank code : 7010;   Branch code : 627) and drop an email to comsaa@rocketmail.com about the transfer.
Members who pay the membership fee before 31st December 2011, will become Founder Members of CoMSAA.
Prof. Athula Kaluarachchi
Secretary, CoMSAA
Faculty of Medicine,
P.O. Box 271, Kynsey Road,
Colombo 08, Sri Lanka.

Contact Details:
Postal Address:                         Email: comsaa@rocketmail.com
                                Phone: 0115849567




For office use only  


Membership No:
Founder Member: Yes/ No  
Membership Category: Full Member / Associate Member/ Honorary Member      
Amount Paid:………………………              
Receipt No:   …………………........  
Cheque number:…………………….              
Eligibility:     Eligible/ Not Eligible
Date of Approval by the Executive Committee:……………………………….
Date of informing the member:………………………………………………...
…………………………….                ……………………………  
Signature of the Secretary                    Date