Membership Form

You need to submit your proof of payment (photo of Cheque/ Screenshot of UPI payment) while submitting the form

First Name

Last Name

Password (Set password for future login)

Upload Your Passport size Photo*

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Date of Birth

Permanent Address

Hospital/Clinic Address*

Mobile Number*

E-mail Address

Qualifications*

Designation*

Registration No.*

Please attach your (i) Medical Council Certificate`*

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

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Mode of Payment:*

Date of Payment

Upload your proof of payment(picture of Cheque/ UPI screenshot)*

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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

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Payment Summary

Registration Fee: Rs. 2000

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