Membership Form

Member Details Academic Details Workplace Details Reference Details Attachment Details User Details

SELECT RESIDENCE TYPE

Nepalese Resident

Foreign Currently on Nepal

Nepalese Currently on Abroad

Member Type *

PROFILE

First Name * ^{(Don't mention Dr.)}

Middle Name

Last Name *

Date of birth(BS) *

Date of birth(AD) *

Gender: *

Male

Female

Others

Mobile Number *

Email *

Nationality *

National ID Number

ADDRESS

Permanent Address *

Current Address *

Permanent woda *

Temporary woda *

Permanent Street *

Temporary Street *

State Name *

City Name *

Street Name *

ZIP/Postal Code *

Current Address *

Temporary woda *

Temporary Street *

Permanent Address *

Permanent woda *

Permanent Street *

Current Address *

State Name *

City Name *

Street Name *

ZIP/Postal Code *

Medical Council Number *

Medical Council Passed Year *

Council Specialization Number (*If you have*)

Specialization Passed Year (*If you have*)

Academic Degree *(Note: Enter Running on MD passed date incase of not completed)

Course	Abbreviation	Joined Date	Passed Date (AD)	University Name

Work place *

(Please provide reference details of registered SAN member)

Name *

Email *

SAN Member No*

Phone *

Address *

Work Place *

Photo(Image less than 500KB is required)

Voucher(Image/PDF less than 500KB is required)

Council Certificate(Image/PDF less than 500KB is required)

Council Specialization Certificate(Image/PDF less than 500KB is required)

Username

Password