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Conference Registration

Every physician or dentist has to independently register for the conference. For example if the spouse is a physician or dentist and likes to attend the conference sessions then please submit the registrations separately.

Registration is free. The registration deadline is September 12, 2009.

Some of the input fields are not valid. They are marked with an error message in Red color. Please correct these errors and re-submit the page.

General Information

First Name*   Middle Name Last Name*
Address*
City*		State/Province
Zip/Postal Code		Country*	Argentina Australia Brazil Canada China Colombia Croatia El Salvador France Germany India Indonesia Iran Israel Italy Japan Kenya Lebanon Malaysia Mexico New Zealand Peru Russia Singapore South Africa Sri Lanka Tanzania Thailand Uganda UK Ukraine USA Venezuela Other
	Please enter the Country
Email*		Confirm Email*
Primary Contact Phone*		Mobile Contact Phone
Language(s)	Select From   Selected Afrikaans Arabic Cantonese English French German Gujarati Hindi Japanese Kannada Korean Malay Mandarin Polish Portuguese Spanish Tamil Telugu Thai Urdu Vietnamese Other
Enter Value

Multiple values can be selected by selecting a value from the “Select from” column and clicking the green plus symbol . To remove a value select the value from the “Selected” column and click the red minus symbol .

Professional Information

Speciality	Select From   Selected Anesthesiology Cardiology Clinical Epidemiology Critical Care CV Surgery Dermatology Emergency Medicine Endocrinology ENT Gastroenterology General Internal Medicine General Practice Hematology Infectious Diseases Neonatology Neurology Neurosurgery Nuclear Medicine Obstetrics and Gynecology Oncology Ophthalmology Oral and Maxillofacial Surgery Orthopedic Surgery Pathology Pediatrics Plastic Surgery Psychiatry Pulmonology Radiology Rehabilitation Medicine Rheumatology Sports Medicine Transplant Medicine Transplant Surgery Urology Other
Enter Value
	Multiple values can be selected by selecting a value from the “Select from” column and clicking the green plus symbol . To remove a value select the value from the “Selected” column and click the red minus symbol .
Certification	Select From   Selected AGAF BChD BDS FAAA FAACAP FAAAAI FAAD FAADM FAAEM FAAFM FAAFP FAAIM FAAN FAAO FAAOS FAAP FAAS FACC FACE FACEP FACFP FACG FACHM FACMI FACMPE FACN FACOEP FACOFP FACOG FACOI FACOOG FACOP FACOS FACP FACR FACS FACSM FAHA FAOAO FAOCP FAOCR FAPA FASCP FCAP FCCM FCCP FDSRCS FRCA FRCO FRCOG FRCP FRCS MFDSRCS MRCO MRCP Other
Enter Value
	Multiple values can be selected by selecting a value from the “Select from” column and clicking the green plus symbol . To remove a value select the value from the “Selected” column and click the red minus symbol .
Qualification	Select From   Selected BA BPharm BSc/BS ChB DGO DO DPath DRCOG MA MBBS MBChB MCh MD MSc/MS PharmD PhD RGN RN Other
Enter Value
	Multiple values can be selected by selecting a value from the “Select from” column and clicking the green plus symbol . To remove a value select the value from the “Selected” column and click the red minus symbol .
CV in Word Format

	Clinical Practice and Experience
	Research Experience
	Research Grants received
	Academic Teaching Experience
	Experience with Disaster Relief
	Experience with Medical Camps
	Retired from Active Practice
	Belong to a Sathya Sai Center

Do you have a current License for Independent Practice?*

None

Temporary

Permanent

Expiry Date of Current License for Independent Practice*

January February March April May June July August September October November December     2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020

Volunteer to provide Medical Care

Do you have Registration for Medical Council of India?

None

Temporary

Permanent

Medical Council of India Registration Expiry Date*		January February March April May June July August September October November December     2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020
Medical Council of India Registration Number*

How much Lead Time do you Require to be Notified to Serve in a Health Mission? *

Less than 4 weeks Between 4 and 8 weeks Between 8 and 12 weeks Greater than 12 weeks Not Interested

General Comments

Once approved the sign in details will be emailed to the given email address.