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Member Registation Form
Retrive Data
Member Registation Form
Personal Information
First Name
Middle Name
Last Name
Email
Mobile Number
Type of Profession*
Choose Type of Profession
Pharmacist
Pharmacy Assistant
Registration Certificate Number
-
Citizenship Number
Passport Number
Gender
Male
Female
Other
Permanent Address
Province*
Choose Province
Koshi Province (काेशी प्रदेश)
Madhesh Province (मधेश प्रदेश)
Bagmati Province (बाग्मती प्रदेश)
Gandaki Province (गण्डकी प्रदेश)
Lumbini Province (लुम्बिनी प्रदेश)
Karnali Province (कर्णाली प्रदेश)
Sudurpaschim Province (सुदुरपश्चिम प्रदेश)
Ward number
Working Address
Same as Permanent Address
Province *
Choose Province
Koshi Province (काेशी प्रदेश)
Madhesh Province (मधेश प्रदेश)
Bagmati Province (बाग्मती प्रदेश)
Gandaki Province (गण्डकी प्रदेश)
Lumbini Province (लुम्बिनी प्रदेश)
Karnali Province (कर्णाली प्रदेश)
Sudurpaschim Province (सुदुरपश्चिम प्रदेश)
Ward number
Institute Name
Details relating to educational qualification
Educational Qualification
University/Board
Year
Division
Educational Qualification
University/Board
Year
Division
Educational Qualification
University/Board
Year
Division
Specialization
Details relation to Professional Activities
Choose your field*
Choose Type of Profession
Hospital
Community
Regulatory
Academic
Industrial
Others
Organization name
Post
Year
Duration
Current
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