Registration Form

Prefix

Full Name

Print Name on Certificate Badge (Don't write Dr./ Prof./ Mr./ Mrs.)

Gender

Date of Birth (DD/MM/YYYY)

Mobile Number

Current Working Details

Current Designation

Name of Current Institution/ Organisation/ Company

Address of Current Institution/ Organisation/ Company

State

City

Pincode

Academic Qualification Details

Qualification (Only qualifications recognized by NMC / MCI)

Name of Regulatory Body (MBBS / MD Registration Detail)

Registration No

Date of Registration (DD/MM/YYYY)

Workshop Details

Are you interested in attending Pre-conference workshop?

Yes

Accompanying Person Details

No. of Accompanying Person

All the information given here with by me is true to the best of my knowledge andin case of any discrepancies, I will be liable to actions as per the rules ofassociation. I will abide by the rules and regulations of national association of pharmacology and therapeutics.

Note:- Once the registraion has been done refund will not be possible.