TNPCIAPM | Member Registration

Member Registration Form

All fields marked with * are required

Membership Type *

Fee Payable

Amount Rs. 3,000

Full Name *

Email Address *

Password *

Date of Birth *

Gender *

Profile Photo *

Mobile Number *

WhatsApp Number (optional)

Address Line 1 *

Address Line 2 (optional)

City *

State *

Country *

Pincode *

Organization Name *

Designation *

Qualification *

College Name *

Graduation Year *

State Medical Council No. *

Medical Council State *

Reference Membership No. 1 *

Reference Member Name 1 *

Reference Member Email 1 *

Medical Council Certificate *

Degree Certificate *

Payment Proof *

By submitting, you confirm that all information provided is accurate and complete to the best of your knowledge.

Transfer fee before submitting

Account Name TAMILNADU AND PONDICHERRY CHAPTER IAPM

Account Number 38132954230

IFSC Code SBIN0007231

Bank & Branch State Bank of India Peelamedu Branch, Tamil Nadu

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Upload screenshot of payment as proof with the registration form