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Title

Prof.
Dr.
Ms.
Mr.

Full Name*

How you would like your name to appear on the Badge, Certificate and all records *

Email Id *

Mobile Number *

Designation

Affiliation (Institute / Hospital / Organization) *

Address of the organisation

Gender *

Meal Preference *

Country *

City *

State *

Pin Code *

Professional Registration Number (NMC,State Medical Council, RCI/NHPAC & Others)

Category *

Category Type

IPS Membership No. *

Old Number System

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LAM or LOM Membership no.

IPS Membership No. *

Accompanying Name *

Accompanying Relation *

Upload Document- Proof of Bonafide Student Status*

Do you want register Accompanying Person ? *

DOB *

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Name

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Age

DOB (As per the ID Prof Like Aadhar Card, Passport & ETC)

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Workshop Basic Fee *

Workshop GST Fee *

Workshop Total Amount *

Conference Registration Payment Details

Conference Total Amount *

Accompanying Payment Details

Accompanying Total Amount *

Total Amount *

Payment Date *

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