Registration – IRSP

REGISTRATION FORM

FIRST NAME *

LAST NAME *

PREFERED NAME ON CERTIFICATE *

POSITION *

INSTITUITION / MEDICAL COLLEGE *

ADDRESS

MOBILE NO. *

EMAIL *

QUALIFICATIONS *

PMDC REGISTRATION / IRSP MEMBERSHIP NUMBER.

REGISTRATION PASS TYPE *

CONSULTANT
RESIDENT/ TECH / STUDENT
SPEAKER
MODERATOR / CHAIR

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