Registration for Annual Academic Session – 2021

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Salutation :

Full Name :^*

Name With Initials :^*

Preferred Name :

National Identity Card No (NIC):^*

Gender :^*

Male
Female

Date of Birth :^*

Contact Information

Email^*

Postal Address :

Address Line 1 ^*

Address Line 2 ^*

City ^*

State or Region

Country

Zip

Place of work and Address :

Hospital

Mobile

Office

Residence

Fax

Preferred contact number for Communication :^*

Professional Qualification

Medical Degree (with details) :^*

Medical School :

Post Graduate Qualifications (with dates) :

a). Diagnostic Radiology/ Radiotherapy & Oncology. b). Other Qualifications

Non Radiology Consultant (Rs 6000.00)
Radiology Consultant (Rs 5000.00)
Non Radiology Trainee (Rs. 4000.00)
Radiology Trainee (Rs. 3000.00)

Special Interest :

Username^*

Password^*

Password must be at least 7 characters long.

Enter password again^*

Password must be at least 7 characters long.

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