Indian Pharmacy Graduates' Association in New Delhi, India

Personal Details

Membership No (For Office Use only)

Designation (For Office Use only)

Last Name / Surname

First Name *

Middle Name

Photo *

PERMANENT ADDRESS *

State *

Town / City / District *

Pin Code *

Contact Number *

E-mail *

Date of Birth

Blood Group

Official Details

OFFICIAL ADDRESS WITH DESIGNATION

Organisation

ADDRESS

Pin Code

Qualification Details

*Please enclose photocopy of your B. Pharm/Pharm D. Degree Certificate.

Education *

Year of Passing *

Name of Institute

University

Upload Degree Certificate

Files must be less than 4 MB. Accepted file types: jpg jpeg png pdf doc docx.

Payment Details

**Enclose Draft/Cheque* in favour of "IPGA New Delhi" (Sections 29-32 are not applicable for online payment of Membership Fee.)**

Type of Membership (Put check in the appropriate box) *
Life Member Associate Life Member Institutional Member

Amount (in words)

Cheque/Draft / Pay order No.

Dated

Drawn on (Bank Name)

Please check in the appropriate column *
Pay Online Cheque Draft / Pay Order

NOTE: Payments made online may take up to 48 hours to be received and reflected in our records. Please allow up to 48 hours for your payment status and membership details to be updated. We appreciate your patience and request that you refrain from making a duplicate payment during this processing period.

Place *

Date *

UNDERTAKING * Certified that the information given in the form are true to the best of my knowledge. I shall abide by all the rules and regulations of the Indian Pharmacy Graduates' Association

Membership Form