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Membership Registration Form
Member details
Member Type*
Select a member type
Hospital
Labs/Diagnostic
Other
Other Member type*
Name*
Address Line*
State*
Select a State
Manipur
District*
Select a District
Pincode*
Email*
Website
PAN No. / GST No.
Phone No*
+91
Unverified
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This number will be used for account login. You need to verify it by clicking Send OTP button.
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Authorised Contact Person Details
Authorised Person (Primary)
Name*
Designation*
Phone*
Email*
Authorised Person (Secondary 1)
Name
Designation
Phone
Email
Authorised Person (Secondary 2)
Name
Designation
Phone*
Email
Head Of Institute Details
Name*
Designation*
Phone*
Email*
Aadhaar No.*
File Uploads
Registered Certificate*
PAN Card / GST Certificate
Aadhaar of Head*
Once this form is submitted you will not be able to make any changes except authorised person details. So, kindly enter all the details correctly.
I hereby declare that the information provided on this form is true and correct to the best of my knowledge and belief. I understand that any false or misleading information may result in the rejection of this application or other disciplinary action.
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