Membership No (For Office Use only)

Photo

Name

Father Name *

Date of Birth

Blood Group

Permanent Address *

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

Pin Code *

Whatsapp Number *

Email-id *

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

Pin Code *

Office / Institution Address

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

Pin Code

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

"Any Other Professional Degree/ Diploma related to Pharma & Healthcare:

Name of Institute/University

Student Membership*
Associate Member: (rs.500/-1 (valid For Three Years Only)
Lifetime Member: (rs.1050/-1 (valid Up To Lifetime)

Working Professional Membership*
Associate Member: (rs.1100/-] (valid For Three Years Only)
Lifetime Member: (rs.2100/-] (valid Up To Lifetime)

Institutional/ Company / Firm Membership: *
Associate Member: (rs.3100/-1 (valid For Three Years Only)
Lifetime Member: [rs.5100/-] (valid Up To Lifetime)