Membership Form

Download Membership form

First Name *

Middle Name

Family Name *

Date of Birth *

Gender

Nationality

Contact Info

Address

Tel

Fax

Email *

Hospital/Office *

Tel

P.O. Box

Designation *

Clinic

Tel

Medical Council Regd. No. *

Name of Council *

Country

MBBS or Equivalent Qualification

Degree *

Name of university/institution *

Year of qualification *

Specialists Qualification

Degree

DLO
FRCS
MS

Name of university/institution

Year of qualification

Enclosures

Upload MBBS or equivalent certificate

Upload graduate Diploma/Degree/Fellowship

Upload citizenship certificate *

Upload medical council registration certificate

Upload specialist registration certificate

Upload Photo *

Concept by: Sujan S Chhetri