Registration Form
Title :
Dr
Prof
Mr
Mrs
Ms
First Name *
Last Name *
Address *
City *
State
State Medical Council Registration Number *
Mobile (WhatsApp) without 91 only 10 digit *
Email *
Registration Category
Delegate
Total Paid Amount
Mode of Payment *
Select
Cheque
DD
NEFT/RTGS/Paytm/Phonepay/Googlepay
Transaction No. *
Upload Payment Screenshot *
* Screenshot of “Payment Success” required please upload file