Registration Form

Full Name: CNIC: Date of Birth: Current Professional Position: Current Institutional Affiliation Qualification:

Write Other Qualification:

Country: City: Home Address: Office Address: Landline: Mobile: FAX: Email:

Select Address:

Would you like to receive PBMT updates ? YES Reference:

Payment Methods: Cash on Desk BANK / ATM Deposit Date: For Year: Deposit Amount:

Contact Info

Executive Membership (EM) - PKR 10,000 / year

Associate Membership (AM) - PKR 2000 / year

Undergraduate Membership (UM) - Free

Account Title : Pakistan Blood & Marrow Transplant
Account Number :
Bank Name :
Branch Name :
Branch Code :
City : Rawalpindi