Personal Information

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Address (Residence)


Highest Qualification


For Life Membership: Please Attach MCI/ State M.C. Reg. No for Speciality/MBBS/P.G. Training
For Associate Membership: Please attach appropriate council Registration certificate


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Designation with Specialty Work Institute From Date To Date
Declaration : I hereby declare that all the above details are correct. I wish to be a member. I have carefully read the instructions. I shall abide by the Rules, Regulations & Bye-Laws of the Society as in force and any subsequent amendment(s) made from time to time
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Membership Fee

  • Life Member Rs.2000/-
  • Associate Member Rs. 1500/-
  • SAARC Nation Member Rs. 2500/-
  • Non SAARC Nation Member USD$ 100