ISPRP Association

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 : Enter Last Name

* Date of Birth : Enter Date of Birth Enter Valid Date (DD/MM/YYYY)

* Membership Type :

Life Member

Associate Member

Student Associate Member

select Membership Type

* Speciality :

Endodontics

Periodontics

Prosthodontics

Other

Select Speciality Enter Speciality

* Institution/Hospital Name : Enter Institution or Hospital Name

* Gender :

Male

Female

Select Gender

* Blood Group : Enter 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 : Enter Residence Address

* Pin Code : Enter Pin Code

* Residence Country : Select Country

* Residence State : Select State

* Residence Contact Number : Enter Residence Contact Number

Communication Address

* Communication Address : Enter Communication Address

* Pin Code : Enter Pin Code

* Communication Country : Select Communication Country

* Communication State : Select Communication State

* Communication Contact Number : Enter Communication Contact Number

View Registration Amount

Sl No.	Membership Type	Amount
1	Life Member	4500.00
2	Associate Member	4500.00
3	Student Associate Member	4500.00

Payment Details

BANK DETAILS

Bank : Canara Bank ABSMI DERALAKATTE BRANCH
IFSC code: CNRB0010245
Account No. : 02452200041220

Mode of Payment :

NEFT

OTHER

For any payment related clarification Contact :
Dr. Manuel S. Thomas,
Hon. Secretary - ISPRP,
Dept of Conservative and Endodontics,MCODS,
Light House Hill Road, Mangalore-575001
Mobile Number : +91 9980981150
Email: isprpsecretary@gmail.com

* Amount Paid : Rs. 4500 + 18% GST = Rs. 5310 Enter Amount

* Paid On Date : Enter Valid Date (DD/MM/YYYY) Enter Date

* Transaction Number : Enter Transaction Number

* A/C Holder Name : Enter A/C Holder Name

* Bank Name : Enter Bank Name

* Branch: Enter Branch Name

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

Login Credential

* Email id : (This will be your Login Id) Enter Email Id Enter valid email

* Password :

* Confirm Password : Re Enter Password Password Mismatch

What is the sum of :

* 3 + 3 = Enter Captcha