REGISTRATION FORM
Title *
Choose Title
Dr.
Prof.
Mr.
Ms.
Full Name *
Email *
Mobile No. *
City *
State *
Gender *
Male
Female
Designation
Hospital
IMA Branch
PMC Number
Fees
Conference Category *
Select Category
Delegate (IMA Member)
Delegate (Non-IMA Member)
PG Students (Only Conference)
PG Students (Conference + Workshop)
Accompanying Member
Register as *
Select Register As
Delegate (Single) [Only Conference]
Delegate (Single) [Conference + Workshop]
Delegate (Couple) [Only Conference]
Delegate (Couple) [Conference + Workshop]
Delegate Couple Name *
Delegate Couple Phone *
Delegate Couple PMC Number
Please upload the Student ID here *
Amount *
Scan the QR code below and complete the required payment
This amount is inclusive of 18% of GST
Keep the Transaction ID/Number readily available .
Transaction ID *
Please upload the payment Screenshot here *
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