Name of Delegate

Gender

EIZOC Membership No (Optional)

Name of Associate delegate/Spouse/PG (1)

Name of Associate delegate/Spouse/PG (3)

Name of Associate delegate/Spouse/PG (2)

Name of Associate delegate/Spouse/PG (4)

Contact No

Email Address (Optional)

City

State

Pincode

Registration Category

Registration Amount (Cumulative as per Brochure).

Transaction Date (dd-mm-yyyy)

Transaction ID

Remarks (if any)

Please make the payment before applilcation and give the Transaction number in application form

Members can Login to get their details filled (Optional).

Account Name : OSOM

Bank Detail :
Bank - BANK OF BARODA
Branch : Aizawl

A/C No :
76680100002210

IFSC Code :
BARB0VJAIZA

Registration Form