test – Global Association of Physicians of Indian Origin

Title*

Passport Size Photo*

First Name*

Last Name*

Primary Medical Qualification*

Additional Qualification*

Speciality*

Registering body/Medical Council/American Board*

Registration/Licence Number*

DOB*

Email*

Select Country

Town

Postal Code

Permanent Address*

Telephone*

Area Code

-

Phone Number

Mobile*

Current Occupation: In service /Self-employed/Retired/Students*

Name of the Employer/Organization*

Position

Are you member of any association overseas

Yes

No

Are you member of any association in India

Yes

No

Name/s of the relevant association/s and name of country

Please include a statement of the contribution you may have made in the health care sector

Acceptance Declaration:
I hereby apply to become regular member of GAPIO and declare that all the particulars mentioned above are true to the best of my knowledge and belief and nothing has been concealed therein. I further undertake to abide by the rules and regulations of GAPIO. I further declare that I am in good standing with main registration body/ medical council.

Since this from is submitted online, therefore no signature is required.

Date

Please attach the self attested copy of the following documents: *

Registration Certificate*

Driving License / Passport*

Medical Degree certificate*

Acceptance Declaration:
Amount of Admission Fee for Regular Members: INR 2950/- (Two Thousand Nine Hundred and Fifty Only) or equivalent in foreign currency.
Please send completed application form with payment through cheque drawn in favour of "Global Association of Physicians of Indian Origin" to:

I understand that membership formalities will not be complete in the absence of my KYC documents. Therefore I will submit the KYC documents within 15 days.