Life Membership – Peradeniya Medical School Alumni Association

Name:

First Name Required Last Name Required

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Address Line 2: Address Line 2 is not valid

City:* City is Required

Country:* Country is Required

State/Province:* State/Province is Required

Zip/Postal Code:* Zip/Postal Code is Required

Title:* Title is Required

Batch (e.g. 1996/97):* Batch (e.g. 1996/97) is Required

Current Profession:* Current Profession is Required

Speciality: Speciality is not valid

Current Work Institute(s):* Current Work Institute(s) is Required

Phone Number:* Phone Number is Required

Email Address:* Email Address is Required

I declare that the information provided in this application is true and accurate to the best of my knowledge. *

Username:* Invalid Username

Email:* Invalid Email

Password:* Invalid Password

Password Confirmation:* Password Confirmation Doesn't Match

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Pay Peradeniya Medical School Alumni Association

$200

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	Life Membership – Payment $200	$200.00
	Total	$200.00

Life Membership – Payment

$200

$200.00

Total

$200.00