21, E–Block, Panki, Kanpur, UP, India.
mpcckanpur@gmail.com
(+91) 923 5659 305 | 923 5659 306
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Online Member
Registration Form
NOTE :
1. Along with the Registration Charges an advance for 6 months is payable Online.
2. Once the Request form is submitted in STEP 1, The Service route and other verification is done by our staff then only you can make The Online payment using STEP 2.
3. The Membership shall be subjected to the Admins' approval after the form submission and if any data is found incorrect / False, upon verification, the membership shall be Rejected/Suspended.
STEP 1: Fill in the Form and Click "SUBMIT NEW REGISTRATION" button.
Name of The Institution / Party
*
Select City & Zone
*
--Select City & Zone--
AURAIYA * KANPUR
BANDA * JHANSI
BASTI * GORAKHPUR
DEORIA * GORAKHPUR
DHERADHUN * UTTARAKHAND
ETAWAH * KANPUR
FATEHPUR * KANPUR
GORAKHPUR * GORAKHPUR
HAMIRPUR * KANPUR
HARIDWAR * UTTARAKHAND
JHANSI * JHANSI
KANNAUJ * KANPUR
KANPUR DEHAT * KANPUR
KANPUR NAGAR * KANPUR
KUSHI NAGAR * GORAKHPUR
LALITPUR * JHANSI
MAHOBA * JHANSI
MAHRAJGANJ * GORAKHPUR
ORAI * JHANSI
PAURIGARWAL * UTTARAKHAND
SANT KABIR NAGAR * GORAKHPUR
SIDDHARTH NAGAR * GORAKHPUR
UNNAO * KANPUR
Route
Area
Institution Type
*
(Please select the closest option to avoid further problems)
--Select Institution Type--
Blood Bank
Clinic
Clinic & Pathology Centres
Dental Clinic Per Chair
Discarded (Expiry)Medicines*
Dispensary
HOSPTAL MORE THAN 101 BEDS
HOTEL/RESTAURENT ABOVE 100 ROOMS
HOTEL/RESTAURENT UPTO 100 ROOMS
HOTEL/RESTAURENT UPTO 25 ROOMS
HOTEL/RESTAURENT UPTO 50 ROOMS
Institutions
Medical Store
Nursing Home / Hospital (1-10 Beds)
Nursing Home / Hospital (11-20 Beds)
Nursing Home / Hospital (Above 21 Beds)
Pathology (Up to 1000 collection per month)
Pathology (Up to 1500 collection per month)
Pathology (Up to 3000 collection per month)
Pathology Collection Center
Pharmaceuticals Company (upto 200 kg/month)
Poly Clinic
Surgical clinics
Veterinary clinic
Veterinary Hospital
No. of Beds / Rooms / Chairs as applicable
Note : A Basic Material Package is mandatory for new registration of any Institute / Clinic / Pathology.
The Amount is payable in advance with the Registration Fee.
Registration Charge (One Time)
*
Monlthy Rates per unit
*
Monthly Charge per Month
*
Total Payable Amount (Amt. Includes 12% GST)
*
Address
*
Pincode
Mobile No. (Do not use 0 or +91)
*
Email
*
Contact Person
*
Owner Name
Adhaar#
GSTN
Payment Mode
*
Online Payment
IMPS / RTGS
Cheque Deposit
Cash Deposit / Draft
Payment Dt. e.g. 01-Jan-2019 or Cheque dt.
*
IMPS / RTGS Transaction ID / Cheque No.
*
Upload Deposit Slip Picture
JPG/JPEG/PNG/BMP File At Max. 2MB
*
*
Mandatory Fields
Submit New Registration
Reset
STEP 2: To make An Online payment for the Approved Registration Request
Click "Make Online Payment" Button.
Make Online Payment
OTP
Verification
Please provide the verification code sent to your mobile number to complete the member registration process.
Verify To Proceed The Payment
Not Received Any OTP? Resend
*
Mandatory Fields