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 :

* Date of Birth :

* Membership Type : Life Member
Associate Member
Student Associate Member

* Speciality : Endodontics
Periodontics
Prosthodontics
Other

* Institution/Hospital Name :

* Gender : Male
Female

* 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 :

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. Vibha Shetty,
Faculty of Dental Sciences,
Ramaiah University ofApplied Sciences,
Gnanagangothri Campus
New BEL Road, Bangalore-94
Mobile Number : +91 9845305455
Email: isprpsecretary@gmail.com

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

* Paid On 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 :

* 4 + 1 =