Registrations - DIAS

Name:

Date Of Birth:

Age

F/M/Husband Name

Email

Address:

Address 2

Mobile No:

Alternate No:(Optional)

Course Opting For:

Choose Courses:

Duration

Training Fee:

Consumables Fee

ASI Fee

GST:

Total Fee:

Year of Passing(MBBS):

Year of Passing(MD/MS):

GST Number(Optional):

Years/Months of Experience in Injectables:

Scrub Size:

Preferred Center 1

Preferred Center 2

Preferred Center 3

Select Nationality

For International Only

BOARD CERTIFIED BY

DURATION OF THE COURSE

REGISTRATION NO.:

BOARD CERTIFIED Document Upload Here

REGISTRATION NO. Document Upload Here..

For Indian Only

Choose Qualification:

Occupation (If any):

MCI Registration No:

IADVL No.:

Qualification:

Occupation (If any):

MCI Registration No:

IADVL No.:

Date of Registrstion:

Photograph:

Signature:

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