ASN REGISTRATION FORM

Fill in this form and submit for approval

Membership Type

Life Member (Single) - ₹3000

Life Member (Couple) - ₹5000

Associate Member - ₹3000

Student Member - ₹500

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Personal Details

Full Name *

Qualification *

Speciality *

Medical Registration Number *

Hospital / Clinic

Date of Birth

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Contact Details

Mobile Number *

WhatsApp Number

Email Address *

City

State

PIN Code

Full Address

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Upload Documents

Passport Photo

Registration Certificate

Qualification Certificate

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I hereby certify that all the information furnished above is true and correct to the best of my knowledge.

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