PSS Membership Form

First Name * Middle Name * Last Name * Date of Birth *
Upload Member Photo (in .pdf format, upto 2 MB file size) * Choose file
Highest Qualification * Speciality * Medical Council Registraion Number Address
Address Line 1 *

City *

State *

Posta Code *

Country *

Upload Resident Photo * Choose file
Mobile No. * Alternate Mobile No. Email Id. * {{-- Transation Details /Payment Method

Online

Offline

Cheque / DD

NEFT/ RTGS / IMPS

Number/ Transaction Id: * Date *

Bank Name *

Branch Name *

Amount *

Upload Payment Proof * Choose file

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