RxDentistry

Registartion Form

Fields Marked (*) are mandatory and rest can be left blank.

Name*

Father's Name*

Date Of birth *

(dd /mm /yyyy)

Email*

This is where your password will be sent.

Cell No. *

Enter valid 10 digit mobile number.Syllabus distribution for various tests will be informed through sms

Residence No.

Sex

Male Female

Education*

College

Select Course

Address*

Enter complete and correct postal address.Hard copies of exams will be sent to this address.

City

State

Pin Code

Country

Promotional Code

Have Promotional code Not Have Promotional code

I ACCEPT THE TERMS AND CONDITIONS, I understand that the Registration fee paid will not be refunded under any circumstances and I also agree to receive Rx Dentistry SMS on my mobile even after DND registration.

	MODE OF PAYMENT
DEPOSIT - FOR NBDE PART 1 SUBJECT –WISE SERIES Rs. 6500/-( 130 US $) - FOR MOCK TEST SERIES Rs. 2500/- (50 US$)


	BY PAYPAL/CREDIT CARD

	BY DIRECT BANK TRANSFER IN THE FOLLOWING ACCOUNT	PUNJAB NATIONAL BANK ACCOUNT NO: 1794002100116905 BRANCH : AMRITSAR(PUNJAB) NAME: Rx Dentistry



	BY BANK DRAFT	In favour of "Rx Dentistry" payable at Amritsar. MENTION YOUR NAME : PHONE NO: COURSE JOINED: AND SEND TO Dr. SOURABH MADAAN C/O SWIFT SALES SERVICES QUEEN'S ROAD, OPPOSITE HOTEL SUNCITY TOWERS, AMRITSAR.



	BY ELECTRONIC TRANSFER (NEFT)	IFCS NO:PUNB0179400 ACCOUNT NO: 1794002100116905 BRANCH : AMRITSAR(PUNJAB) NAME: Rx Dentistry

Fill the following details:


DATE OF DEPOSIT:*
TRANSACTION ID:*
CITY :(where you deposited money)*
POSTAL ADDRESS WITH PINCODE*:
E-MAIL ID*:
COURSE JOINED*