Registration Form

Full Name(as required on the certificate)*

Email Id*

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

Gender*

Institute

Country*

Address

City*

State*

Category*

Medical Council Registration Number*

Meal preference

Do you want to attend Masterclass? *

Do you want to attend Gala Dinner?*

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 *

Terms & Conditions *