Online Registration


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To View Registration Amount click here -->  View Amount

'*' Fields are Mandatory
* Title :
 
* Name :
 
* Age :
 
Gender :

* Hospital/ Organization/ Institute/
Affiliation/ Clinic Name :
 
* Designation :
 
* Address :
 
* Country :

* State :

* City :

* Pin Code :
 
* Mobile Number :

SMS will be sent to only Indian number

* Email Id :

Dental Council Registration Number :

Council State :

* Registration Type :




 
* IOS Membership Number :
(LM or SLM)
 
Accompanying Persons  :

Food Preference  :
Bank Details

Account Name :
25IOSPGCON2021
Account Number :
8633101411139
Bank Name :
Canara Bank
IFSC Code :
CNRB0008633
Branch Name :
A J HOSPITAL CAMPUS, MANGALURU

Payment Details

* Amount (in Rs) :
 
( Registration )

* Mode of Payment :




 
* NEFT/DD/OTHER Transaction Number :
 
* Payment Date :
   
* Bank :
 
* Account Holder Name :
 
* Upload Scanned Copy of Payment Receipt (NEFT/DD/OTHER) :
(File Size Max 3MB)
 

* Upload Your Recent Passport Size Color Photo :
(Once you select photo, Please Wait for upload)


   


Any other Comments / Request :