Name: 
   Date of Birth: 
   Qualification: 
      Discipline: 
  Postal Address: 
                  
          E-mail: 
                               Phone:    
                                   Fax:     

To recieve Prospectus & Application form, send 35 US $ in favour of "RAMA DENTAL 
COLLEGE -HOSPITAL & RESEARCH CENTRE, KANPUR.

Mode of payment should only be through DEMAND DRAFT(D.D.)
                 D.D No.:   
                      Date:  
                     Bank:    

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