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Full Name(as required on the certificate)*

Email Id*

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

Gender*

Category*

Institute*

Country*

Address*

City

State*

Medical Council Registration Number*

Meal preference*

Do you want to register Accompany? *

Do you want attend Workshop? *

Payment Mode*

Amount*

Bank Details:
Account Name: GENEXT MEDED FOUNDATION
Account No: 50200111758656
IFSC Code: HDFC0007270
Bank Name: CIVIL LINES ROHTAK
Branch Name: HDFC BANK LTD

UTR Id / Transaction Id.*

Transaction Date *

Upload Payment Receipt *

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