Membership Form

First Name

Last Name

Password (Set password for future login)

Upload Your Passport size Photo

Upload

Date of Birth

Permanent Address

Hospital/Clinic Address*

Mobile Number*

E-mail Address

Qualifications*

Designation*

Registration No.*

Please attach your (i) Medical Council Certificate`

Upload

(ii) MS, MD Certificate or Certificate from HOD (in case of resident)

Upload

Mode of Payment:*

Date of Payment

I wish to be a Life Member,*

Declaration by Candidate: I declare that the above details are correct. I shall abide by the regulations of the Society in force and any subsequent amendments made from time to time

Only fill in if you are not human

Login

Payment Summary

Registration Fee: Rs. 2000

Scan the Code above & make the payment, then submit the payment screenshot along with the registration form