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Registration Form

Full Name(as required on the certificate)*

Email Id*

Mobile No.(whatsapp Number only without country code)*

Gender*

Institute*

Country*

Address*

City

State*

Medical Council Registration Number*

Catgeory*

Do you want to register Accompany? *

Payment Mode*

Amount*

Bank Details:
Account Name: NORTH ZONE CHAPTER OF THE UROLOGICAL SOCIETY OF INDIA
Account No: 659301701196
IFSC Code: ICIC0006593
Bank Name: ICICI BANK
Branch Name: AMRITSAR - GOPAL NAGAR

UTR Id / Transaction Id.*

Transaction Date *

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