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Full Name(as required on the certificate)*

Email Id*

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

Gender*

Meal preference*

Institute*

Country*

Address*

City

State*

Medical Council Registration Number*

Category*

Do you want attend Workshop? *

Payment Mode*

Amount*

Bank Details:
Account Name: Mediaxsys
Account No: 225102000000171
IFSC Code: IOBA0002251
Bank Name: Indian overseas bank

UTR Id / Transaction Id.*

Transaction Date *

Upload Payment Receipt *