Registration Form

Personal Information

Full Name*

Print Name* ( As you wish to appear in certificate)

Sex

Date of Birth (DD/MM/YYYY)

Working Information

Current Designation*

Current Institution/Organization/Company (Name / Complete Address / State / Pin Number)*

Current Department/Speciality*

Contact Information

Current Correspondance Address (where membership certificate to be delivered)*

State

City

Pincode

Optional Correspondance / Permanent Address

Mobile Number

Optional Mobile Number

Academics Information

Academics Qualification Details (MD/DNB/DM Pharmacology and Therapeutics is mandatory to apply)*

Name of Regulatory Body (NMC/MCI/State Medical Council)*

Registration No. of Post Graduate*

Date of Registration (DD/MM/YYYY)*

Upload Certificate & Photo

Upload Post Graduate Registration Certificate*(Only jpg upto 2mb)

Upload passport sized Photo*(Only jpg upto 2mb)

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

I have saved the screen shots of my photo/membership form and fund transfer receipt for future record and sent to National Coordinator on WhatsApp No. +91-9528540756

Amount

ADDRESS FOR CORRESPONDENCE VIA COURIER, SPEEDPOST OR REGISTERED POST
National Association of Pharmacology & Therapeutics
ALMERAJ HOPSPITAL Deepshikha Gas Agency Street Bajoria Road
Saharanpur Uttar Pradesh 247001 Ph 9528540756