Email* Name (in full)* Mobile Number* Gender* MaleFemalePrefer not to sayOhter Undergraduate student/ Qualified professional MBBSBDSBAMSBHMS Degree pursuing and year (in case of students) Professional qualifications* Current designation (in office)* Place of Work and District* Address including State* Permanent Residence (if different from place of work) Consent for membership of ASEEM as per eligibility:* Yesnot applicable What motivates you to join this convention?* Any suggestion to organizers for this meeting (write NA if you don't have any)!* Please select your registration fee amount?* --- Undergraduate Student - INR 1000 --- Intern undergraduate - INR 2000 --- Professional (Single) – INR 2500 --- Professional with family – INR 4000 --- Family members aged below 12 years : Free Undergraduate Student - INR 1000Intern undergraduate - INR 2000Professional (Single) – INR 2500Professional with family – INR 4000Other Please specify: Use UPI QR code (UPI ID: TBC) provided below to deposit the registration fees. After submitting the fee, take a screenshot or download the receipt. Upload it to the field given below.Please note that In case, you face any difficulty related to payment, please contact: Dr. B L Daria - +91 95870 04199; secretary.aseem@gmail.com Please submit any evidence of submission of the registration charges. (screenshot or PDF)* Upload passport size photograph Captcha: