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Full Name(as required on the certificate)*

Email Id*

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

Gender*

Meal preference*

Institute*

Country*

Address*

City

State*

Medical Council Registration Number*

Category*

Payment Mode*

Amount*

Bank Details:
Account Name: Association of Surgeons of India
Account No: 0002102000071099
IFSC Code: IBKL0000002
Bank Name: IDBI BANK
Branch Name: Basheerbagh

UTR Id / Transaction Id.*

Transaction Date *

Upload Payment Receipt *

📞 For Any Queries, Please Contact

Dr. Surendra+91 99630 96316
Mr. shivraj thakur +91 90009 42426