Title Mr. Dr. Mrs. Prof.Ms.

Name *

Permanent Address *

Present Address

Photograph (Image Format Only)

City *

State * --Select State-- Andaman and Nicobar Andhra Pradesh Arunachal Pradesh Assam Bihar Chhattisgarh Delhi Goa Gujarat Haryana Himachal Pradesh Jammu and Kashmir Jharkhand Karnataka Kerala Madhya Pradesh Maharashtra Manipur Meghalaya Mizoram Nagaland Orissa Punjab Rajasthan Sikkim Tamil Nadu Telangana Tripura Uttar Pradesh Uttarakhand West Bengal Other

Pin *

Office Tel. No.

Mobile No. *

Date of birth *

E-Mail *

Nationality.

Gender * --Select Gender-- Male Female

MBBS *

DO/DOMS

MS/(Ophth)

MCI Registration No:

Name of Medical Council:

Amount:

Rs. 2500/- + GST(Two Thousand Five Hundread Only+ GST)

Bank Details

Current Account No. 63005037709
Name: MP STATE OPHTHALMIC SOCIETY
Bank Name: SBI (State Bank of India)
Branch: Phool Bagh Chouraha,laskar Gwalior - 474007
IFSC Code: SBIN0004088