Member Registration


Any Queries Regarding Technical Assistance, Please Contact A1 Logics 0824 – 4252005 (9:00 AM – 6:00 PM Working Days)

Please,Make Sure you are ready with the soft copies of the following records before you register.
  • Photos
  • BDS/MDS Certificates
  • Payment Reference Copy



Basic Details

* First Name :
Middle Name :

* Last Name :  
* Date of Birth :

* Membership Type :

 
* Speciality :





   

* Institution/Hospital Name :  
* Gender :
 

* Blood Group :  
* Mobile Number :

* Photo : Note : Image extension should be .gif/.png/.jpg/.jpeg/.bmp format



Certificates


* Graduation Certificate(BDS) : Note : File should be less than 2MB and .pdf format  
* Post Graduation Certificate(MDS) : Note : File should be less than 2MB and .pdf format

Other :
Note : File should be less than 2MB and .pdf format


Residence Address

* Residence Address :  
* Pin Code :  

* Residence Country :  
* Residence State :  

* Residence Contact Number :  

Communication Address

* Communication Address :  
* Pin Code :  

* Communication Country :  
* Communication State :  

* Communication Contact Number :  

Sl No.Membership TypeAmount
1 Life Member 3600.00
2 Associate Member 3600.00
3 Student Associate Member 3600.00


Payment Details

Mode of Payment :

Send D/D drawn in favour of ISPRP payable at Mangalore, Karnataka by courier or registered post to:
Dr Harish Shetty,
Hon. Secretary - ISPRP,
The Dental Care Clinic, 1 Floor, Alake Centre,
Kambla Cross Junction, Opp Ullal General Hospital, Alake, Mangalore–575003,
Mob : 9845414849,
E-mail: isprpsecretary@gmail.com, Web:www.isrp.org


* Amount Paid :  
* Date :

* Transaction Number :  
* A/C Holder Name :  

* Bank Name :  
* Branch:  

* Payment Attachment : Note : File should be less than 2MB  
 



Login Credential


* Email id : (This will be your Login Id)  
* Password :


* Confirm Password :    

What is the sum of :
* 5 + 6 =