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Membership Registration Form

Note: All fields are mandatory

Full Name
Gender

Male Female

Date of Birth
Member Photo
Image should be in JPEG or PNG format and should not exceed 250kb file size
Membership Type

Life Member Provisional Member Associate Member

Contact Address
City
State
Mobile Number
Email Address
Educational Qualifications
Qualification MBBS Certificate
Year of Passing
University
Upload Certificate
File should be in JPEG / PDF format
 
Qualification Post Graduation Degree
(Applicable only for LM & ALM)
Year of Passing
University
Upload Certificate
File should be in JPEG / PDF format
 
Qualification Medical Council Registration
Year of Passing
University
Upload Certificate
File should be in JPEG / PDF format
 
Qualification Letter of Recommendation from HOD
(Applicable only for PLM)
Year of Passing
University
Upload Certificate
File should be in JPEG / PDF format
 
Click here to add more qualification details
Registration fee details for the membership
INR 5,000.00 (both PLM & LM) INR 8,000.00 (ALM)
NEFT Details (If payment not done yet, click here to know NEFT details)
Bank
Date
Amount
Reference Number
Verification
Captcha Image CAPTCHA code
Verification Code