KCIAPM

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

* Name :

* Date of Birth :

Note:Date of Birth format should be dd/MM/yyyy

* Gender :

Male
Female
Other

* Mobile Number :

Whatsapp Number :

Same as Mobile Number

* Country :

* State :

* City :

* Zip / Pincode :

* Permanent Address :

* Designation :

* Name of organization :

* Photo :

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

Reference

* First reference Membership Number :

Member Name :

Member Name comes here

Email Id :

Member Email Id comes here

* Second reference 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 :

* University Name :

* Graduation Year :

* State Medical Council No. :

* Medical Council State. :

Certificates

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

(Only PDF and Word File are Allowed)

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

(Only PDF and Word File are Allowed)

Login Credentials

* Email Id :

(This Email Id Will be Your Login Id)

* Password :

Payment Details

* Mode of Payment :

Online

* Amount:

Including Payment Gateway Charge.

* 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.