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 :

* Name :

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

* Gender :



* 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 details


* College Name :
* University Name :
* Graduation Year :
* State Medical Council No. :

* Medical Council State. :

Certificates

* KMC 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 :

* 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.