Registration Form

REGISTRATION FORM

XII Midyear Conference – 15th-16th July 2024
American University of Antigua
Antigua and Barbuda
Global Association of Physicians of Indian Origin (GAPIO)

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[uacf7-col col:6] Name* [/uacf7-col]
[uacf7-col col:6] Email* [/uacf7-col]
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[uacf7-col col:6] Whether Member or Non-Member* [/uacf7-col]
[uacf7-col col:6] YesNo [/uacf7-col]
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[uacf7-col col:6] GAPIO Membership Number (Applicable to Members only)* [/uacf7-col]
[uacf7-col col:6] [/uacf7-col]
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[conditional condition-not-gapio-member]
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Category	Fee Rs. (Including GST)
Gapio Members	Free
Non-Members (Includes complementary membership of GAPIO to medical graduates)	2950
*Students (Includes Membership to GAPIO)	1180

*Fresh Medical Graduates or Residents – who have passed in 2023, and current DNB Trainees to enclose letter from HOD.
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[uacf7-col col:6] Choose Membership [/uacf7-col]
[uacf7-col col:6] [uacf7_product_dropdown* uacf7_product_dropdown-339] [/uacf7-col]
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[uacf7-col col:6] Address* [/uacf7-col]
[uacf7-col col:6] [/uacf7-col]
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[uacf7-col col:6] City / Locality* [/uacf7-col]
[uacf7-col col:6] State* [/uacf7-col]
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[uacf7-col col:6] Country* [uacf7_country_dropdown* uacf7_country_dropdown-62] [/uacf7-col]
[uacf7-col col:6] Pin / Zip Code* [/uacf7-col]
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[uacf7-col col:6] Mobile Number in India (For Foreign Delegates) [/uacf7-col]
[uacf7-col col:6] [/uacf7-col]
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Name of Account	: Global Association of Physicians of Indian Origin
Name of Bank	: Punjab National Bank
Name of Branch	: Apollo Hospitals, Sarita Vihar, New Delhi, India – 110076 Account
Number	: 50761131000189
Type of Account	: Current Account
IFSC Code	: PUNB0507610 (For transfer of amount from any Bank in India)
Swift Code	: PUNBINBBISB (For remittance from overseas)

CONFERENCE SECRETARIAT:
Mr. Jitendra Malik
Global Association of Physicians of Indian Origin (GAPIO)
Hospital Complex, Indraprastha Apollo Hospital, Sarita Vihar, Mathura Road, New Delhi – 110076
Mobile: +91 – 8527849960 • Email: gapio_delhi@apollohospitals.com