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Member Registration

Any Queries Regarding Technical Assistance, Please Contact 0824 – 4252005 (9:00 AM – 6:00 PM Working Days)

(*) Fields Are Mandatory

Basic Details

* Membership Type :

Life Member

Session Member

Select Membership Type

* Name :

Enter Name

* Date of Birth :

Note:Date of Birth format should be dd/MM/yyyy
Enter Date of Birth Enter Valid Date (DD/MM/YYYY)

* Gender :

Male

Female

Other

Select Gender

* Mobile Number :

Enter Mobile Number

Whatsapp Number :

Same as Mobile Number

* Country :

Choose Country

* State :

Choose State

* City :

Select City

* Zip / Pincode :

Enter Zip/Pincode

* Permanent Address :

Enter Permanent Address

* Designation :

Enter Designation

* Name of organization :

Enter Name of Organisation

* Photo :

(File Size Max 2MB & Format: .gif,.png,.jpg,.jpeg,.bmp)
(Once you select a photo, Please Wait for upload)

Please Upload Photo

Reference

* First reference Membership Number :

Enter Membership Number

Member Name :

Member Name comes here

Email Id :

Member Email Id comes here

* Second reference Membership Number :

Enter Membership Number

Member Name :

Member Name comes here

Email Id :

Member Email Id comes here

Qualification

Academic Details :
MBBS MD DNB DCP

MBBS details

* College Name : Enter College Name

* University Name : Enter University Name

* Graduation Year : Enter Graduation Year

* State Medical Council No. : Enter State Medical Council No

* Medical Council State. : Enter Medical Council State

Certificates

* Med. Council Registration Certificate:
(Maximum Size 2MB)

(Only PDF and Word File are Allowed) Only pdf and word files are allowed!
Upload Ceritificate

* MBBS/DNB/DCP Degree Cerificate:
(Maximum Size 2MB)

(Only PDF and Word File are Allowed) Only pdf and word files are allowed!
Upload Ceritificate

Login Credentials

* Email Id :

(This Email Id Will be Your Login Id) Enter Email Id Enter valid email

* Password :

Enter Password

Payment Details

* Mode of Payment :

Online

* Amount:

Including Payment Gateway Charge.

* Date:

Enter Date

* The information provided in this application form is correct as on the date of submission. I will update the information as and when required to update in the KCIAPM database.

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