Registration Form

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Full Name(as required on the certificate)*

Email Id*

Mobile No.(whatsapp Number only without country code)*

Gender*

Post*

Degree*

Department*

Institute*

Country*

Address*

City

State*

Medical Council Registration Number*

Meal preference*

Payment Mode*

Amount*

Bank Details:
Account Name: PRAYAGRAJ NEUROLOGICAL SOCIETY
Account No: 50200110204044
IFSC Code: HDFC0000226
Branch Name: CIVIL LINES ALLAHABAD
Bank Name: HDFC Bank

UTR Id / Transaction Id.*

Transaction Date *

Upload Payment Receipt *

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