AOPG MEMBERSHIP FORM AOP GUJARAT AOPG MEMBERSHIP FORM AOPG MEMBERLife Membership₹2,000BECOME A MEMBER – FOR PEDIATRICIANS ONLYNOTE : - If you are a CIAP MEMBER & have a permanent resident in Gujarat, you can become AOP Gujarat member by registering with the form below and paying Rs. 2,000/- life membership fee. - Fill all the details as per records in CIAP for verification. - Proposer & Seconder must be members of AOP Gujarat. - Once your details are verified, your account will be activated. After that, you will able to log in to your account. - For any query you can contact us on aopgujarat@gmail.com REGISTRATION FORM All fields marked with * are mandatory to enter * Mobile Number (Username)Allow only 10 digit * Surname * Name* GenderMaleFemale * Email Address * Confirm Email Address * PasswordStrength: Very Weak * Hospital Address * Residential Address* StateGujarat * State * City * CIAP Number* (ex - X/1234/X-1234) - USE ONLY CAPITAL LETTER * Pincode* Profile PictureDone(Use Cropper to set image and use mouse scroller for zoom image.)Done(Use Cropper to set image and use mouse scroller for zoom image.)Drop file here or click to select.jpg, jpeg, png / Max 5 MB* Address ProofDrop file here or click to select.(Upload Government Approved Documents)DETAILS OF PROPOSER (as per CIAP records) * Surname & Name * CIAP Number* (ex - X/1234/X-1234) - USE ONLY CAPITAL LETTER * AOPG Number * MobileAllow only 10 digit * Email ID * CityDETAILS OF SECONDER (as per CIAP records) * Surname & Name * CIAP Number* (ex - X/1234/X-1234) - USE ONLY CAPITAL LETTER * AOPG Number * MobileAllow only 10 digit * Email ID * City Select Your Payment Gateway RazorpayRazorpaySelect Your Payment GatewayHow you want to pay?Auto Debit PaymentManual PaymentPayment SummaryYour currently selected plan : , Plan Amount : Final Payable Amount: PAY NOW