Register

AOPG MEMBER

Life Membership
₹2,000

BECOME A MEMBER – FOR PEDIATRICIANS ONLY

NOTE :

- If you are a CIAP MEMBER & have a permanent resident in Gujarat, you can become AOP Gujarat member by registering with the form below and paying Rs. 2,000/- life membership fee.
- Fill all the details as per records in CIAP for verification.
- Proposer & Seconder must be members of AOP Gujarat.
- Once your details are verified, your account will be activated. After that, you will able to log in to your account.
- For any query you can contact us on aopgujarat@gmail.com

REGISTRATION FORM

All fields marked with * are mandatory to enter

* Mobile Number (Username)

Allow only 10 digit

* Surname

* Name

* Date of Birth

* Gender

Male

Female

* Email Address

* Confirm Email Address

* Password

Strength: Very Weak

* Hospital Address

* Residential Address

* State

* City

* Pincode

* CIAP Number

* (ex - X/1234/X-1234) - USE ONLY CAPITAL LETTER

* Profile Picture

Drop file here or click to select.

jpg, jpeg, png / Max 5 MB

* Address Proof

Drop file here or click to select.

(Upload Government Approved Documents)

DETAILS OF PROPOSER (as per CIAP records)

* Surname & Name

* CIAP Number

* (ex - X/1234/X-1234) - USE ONLY CAPITAL LETTER

* AOPG Number

* Mobile

Allow only 10 digit

* Email ID

* City

DETAILS OF SECONDER (as per CIAP records)

* Surname & Name

* CIAP Number

* (ex - X/1234/X-1234) - USE ONLY CAPITAL LETTER

* AOPG Number

* Mobile

Allow only 10 digit

* Email ID

* City

Select Your Payment Gateway

Razorpay

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Payment Summary

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