Membership Form – Rastriya Ayush Medical Association

Membership Form

MEMBERSHIP REGISTRATION

Upload Your Photo*:

Full Name*:

Date of Birth*:

Gender*:

Nationality*:

Blood group:

Contact Number

Flat No / Street / District / Permanent (or) Correspondence Address:

Professional Details:

Medical Qualification:

Year of Graduation/Expected Graduation:

Medical Registration Number / Student Registration Number:

Issuing Medical Board/Authority:

Specialization (If any):

Flat No / Street / District / Work Address:

Designation/Position:

Identity Proof* (Passport/Aadhar):

Medical Registration Certificate / ID & Marks Card for Students*:

Passport Size Photograph*:

Referred by

Referred by (Doctor’s Name):

Doctor’s Registration Number:

Doctor’s Qualification:

Doctor’s Phone Number:

Declaration:

I hereby declare that the above information provided is true and correct to the best of my knowledge. I agree to abide by the rules and regulations of the Rastriya Ayush Medical Association.

I agree to the Terms and Conditions.

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