Registration & Membership Form

Join the convention and, if you’re eligible, ASEEM membership — takes about 5 minutes.

IV National Convention · Sunday, 18 October 2026

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Step 1

Your details

Email*

Name (in full)*

Mobile number*

We save your progress against this number so you (or our team) can retrieve it later — please use your own number.

Gender*

Step 2

Which best describes you?

🎓

Undergraduate Student

Currently pursuing MBBS, BDS, BAMS or another course

🩺

Qualified Professional

Already hold a professional qualification & are in practice/service

Course*

Please specify your course*

College / university and year*

Professional qualifications*

Current designation (in office)*

Place of work and district*

Step 3

Where you can be reached

Full address including current working state*

Permanent residence (if different from place of work)

Step 4

Membership & your voice

Consent for membership of ASEEM as per eligibility*

Instagram ID

X (Twitter) ID

What motivates you to join this convention?*

Any suggestion to organizers for this meeting*

Step 5

Registration fee & delegates

Undergraduate Student Single registration ₹1,000 Professional (Single) One qualified professional ₹2,500 Professional with family Includes spouse / family attending ₹4,000

👶 Family members aged below 12 years No charge — tell us how many, so we can plan seating and meals 0 Free

Other: Additional Delegate Someone joining you for the convention — added on top of your own registration ₹1,000 each

How many additional delegates?

Total registration fee

₹0

Step 6

Payment & uploads

UPI QR code for ASEEM registration payment

Tap to enlarge

UPI ID: 6660546975@idfcbank

Scan the code or pay to the UPI ID above. Take a screenshot or download the receipt, then upload it below.

BHIM · UPIPaytmGPayPhonePeAmazon Pay

Trouble with payment? Contact Dr. B L Daria — +91 95870 04199, secretary.aseem@gmail.com

Or transfer directly to our bank account

Account Name Baba Saheb ASEEM

Account Number 10238666545

IFSC Code IDFB0042124

Whichever way you pay, please upload the receipt below.

Proof of fee payment (screenshot or PDF)*

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JPG, PNG or PDF — up to 5 MB.

Passport-size photograph

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Captcha*

9 + 8

By submitting, you confirm the details above are accurate to the best of your knowledge.