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Registration Form

*Name :
*Designation :
*Date:
*E-mail :
*Phone Number :
Alternate Phone Number :
*Department :
*Name Of Institute :
*Address :
*City :
*Pin Code :
MC Registration Number :
*Are You member of IAPSM ? :
Yes     No
*Are you member of IPHA ? :
Yes     No
Registration Fee for Pre-Conference Workshop and Conference

For Registration Payment Scan QR Code









ACC No :- 2401235959984646

IFSC :- AUBL0002359

ACC Holder Name :- DR ULHAS PATIL MEDICAL COLLEGE AND HOSPITALCONFERENCEAC

BANK NAME :- AU SMALL FINANCE BANK



*Payment For :
Only Conference
Only Pre-Conference Workshop
Pre-Conference Workshop + Conference
*Payment Mode
*Payment Transaction Id/Receipt Number :
*Upload Payment Slip :
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*Food Preference :
Vegetarian
Non-Vegetarian