Membership Form

Membership No (For Office Use only)

Designation (For Office Use only)

Last Name / Surname

First Name *

Middle Name

Photo *

PERMANENT ADDRESS *

State * Select State Andaman and Nicobar IslandsAndhra PradeshArunachal PradeshAssamBiharChandigarhChhattisgarhDadra and Nagar HaveliDaman and DiuDelhiGoaGujaratHaryanaHimachal PradeshJammu and KashmirJharkhandKarnatakaKenmoreKeralaLakshadweepMadhya PradeshMaharashtraManipurMeghalayaMizoramNagalandNaroraNatwarOdishaPaschim MedinipurPondicherryPunjabRajasthanSikkimTamil NaduTelanganaTripuraUttar PradeshUttarakhandVaishaliWest Bengal

Town / City / District * Select City

Pin Code *

Contact Number *

E-mail *

Date of Birth

Blood Group

OFFICIAL ADDRESS WITH DESIGNATION

Organisation

ADDRESS

Pin Code

Education * Select Degree B.Pharm./Pharm D. M.Pharm. Ph.D.

Year of Passing *

Name of Institute

University

Upload Degree Certificate

Files must be less than 4 MB. Accepted file types: jpg jpeg png pdf doc docx.

Type of Membership (Put check in the appropriate box) *
Life Member Associate Life Member Institutional Member

Amount (in words)

Cheque/Draft / Pay order No.

Dated

Drawn on (Bank Name)

Please check in the appropriate column *
Pay Online Cheque Draft / Pay Order

Rs