TEST AOPG MEMBERLife Membership₹2,000BECOME A MEMBER – FOR PEDIATRICIANS ONLYNOTE : - 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* GenderMaleFemale * Email Address * Confirm Email Address * PasswordStrength: Very Weak * Hospital Address * Residential Address* StateGujarat * State * City * Pincode * CIAP Number* (ex - X/1234/X-1234) - USE ONLY CAPITAL LETTER* Profile PictureDrop file here or click to select.jpg, jpeg, png / Max 5 MB* Address ProofDrop 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 * MobileAllow only 10 digit * Email ID * CityDETAILS OF SECONDER (as per CIAP records) * Surname & Name * CIAP Number* (ex - X/1234/X-1234) - USE ONLY CAPITAL LETTER * AOPG Number * MobileAllow only 10 digit * Email ID * City Select Your Payment Gateway RazorpayRazorpaySelect Your Payment GatewayHow you want to pay?Auto Debit PaymentManual PaymentPayment SummaryYour currently selected plan : , Plan Amount : Final Payable Amount: PAY NOW
