Registration – Medica society

Personal Information

Enter your personal details. Fields marked with
* are required.

Full Name (English) *

Full Name (বাংলা) *

Father's Name (English) *

Father's Name (বাংলা) *

Mother's Name (English) *

Mother's Name (বাংলা) *

Spouse Name *
(Enter N/A if unmarried)

Date of Birth *

Gender *
MaleFemaleOther

Blood Group *

Profile Photo *

Signature Photo *

Address & Contact

Provide your address and contact information.

Present Address

Address *

Division *

District *

Permanent address is same as present

Permanent Address

Address *

Division *

District *

Contact Information

Email *

Phone *

Emergency Contact *

Professional & Academic

Enter your professional and academic qualifications.

Designation *

BMDC Registration Number *

Graduation

Degree *

Institution *

Passing Year *

Post-Graduate Information

Account Password

Password *

Confirm Password *

Membership & Payment

Choose your membership type and complete payment.

Membership Type *

General Member

Yearly Renewal

৳300/year

Life Member

One-time Payment

৳5,000one-time

General MemberLife Member

Payment Summary

General Membership (Yearly)
৳300

Payment will be processed securely via SSLCommerz.

I acknowledge and agree to abide by the Society Constitution and confirm that all information provided is accurate.

I have read and agree to the Terms & Conditions, Privacy Policy and Return & Refund Policy.