Lifetime Membership – AWR SURGEONS

Registration Form

Lifetime Membership(₹12,500.00)

Please Signup

* Username

*

* First Name

*

* Last Name

*

Gender

Male

Female

* Email Address

*

* Mobile Number

*

* Password

*

Strength: Very Weak

Address

Please enter full address with country name.

Designation

Work Details:

Qualification

Clinic/Hospital Name

Clinic/Hospital Number

Enter Number with Country Code

Clinic/Hospital Address

City

State

AP|Andhra Pradesh

Country/Region

Country/Region

Pin Code

About Surgeon

Website (URL)

Select Your Payment Gateway

Razorpay

How you want to pay?

Auto Debit Payment

Manual Payment

Enter Coupon Code

Payment Summary

Plan Selected :
Plan Amount :

Tax Amount :

Coupon Discount Amount :
Final Payable Amount:

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