Ernakulam Psychiatric Society

+91 81291 45425

Email Us

info@epskochi.org

Member Registration

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Member Registration

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Special Salutation(if any)

Full Name (with expansion of initials)*

Name to be displayed in membership directory (use space between initials)*

Gender

Blood Group

Date of Birth

Age

Office Address

Office Address (separated by comma)

State

District

Office Pincode

Country Code

Office Telephone number

Residence Address

Residence Address (separated by comma)*

State*

District*

Residence Pincode*

Country Code*

Residence telephone number*

Mobile numbers (in order of preference)*

Type	Country Code	Mobile Number(10 Digit)

e-mail ID’s (in order of preference)*

Type	Email Id

Medical Council Name

Medical Council Registration No.

Are you an Indian Psychiatric Society member? Yes No

Are you an Indian Psychiatric Society - Kerala State Branch member? Yes No

Are you an Indian Psychiatric Society - South Zone Branch Member? Yes No

Membership in other Psychiatric organizations

Organisation name	Membership Number

Qualifications

Degree	University	College	Passing Year

Work experience as Psychiatrist

Institution	Period From	Period To
		Are you Still Working here?

Family member details (only spouse and children)

Relationship	Name	Date of Birth

Preferred modes of receiving official communication Email SMS Whatsapp Post

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Contact Info

Ernakulam Psychiatric Society,
8th Floor,IMA House Cochin,
Behind Jawaharlal Nehru International Stadium, Palarivattom PO,
Cochin - 682025

Call Us
+91 81291 45425

Email Us
info@epskochi.org