Membership Form

Name

DOB

Degree

Contact Number

Residential Address

Passport Size Photo

Kindly upload completely updated MD/MS certificate ( 2 MB max)

Institution

Department

Communication Address

MBBS

MBBS University

Year of Passing

Post Graduation College

Post Graduation University

Post Graduation Year of Passing

Super Speciality College

Super Speciality University

Super Speciality Year of Passing

Payment Details

Kindly upload the transaction details here in either JPG, JPEG, PNG or PDF format, with a maximum file size of 2MB

The membership fee is Rs.1000/-

Please scan the QR code for payment

Send Chq/dd or NEFT in the favour of:
Account Name :“ISPSM”
Account No: 04852010065966
Name of the Bank: Canara Bank
Manipal Hospital Branch,
98, Rustom Bagh, Bangalore 560017
IFSC code : CNRB0010485

The membership fee is Rs.1000/-

Please scan the QR code for payment

For any clarification please call Ms. Suma S