Name*
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Date of Birth* Day 12345678910111213141516171819202122232425262728293031 Month 123456789101112 Year
Designation* —Please choose an option—Medical OfficerAssistant ProfessorAssociate ProfessorProfessor
BMDC REG*
Medical Collage*
Year of Passing MBBS*
Post Graduation Degree* MD
MD Subject NeurologyNeurosurgeryRadiologyMedicine MD Passing Year MD Institute
FCPS
FCPS Subject NeurologyNeurosurgeryRadiologyMedicine FCPS Passing Year FCPS Institute
Training/Course in Neurointervention Yes
Name of Training/Course Duration of Training/Course Institution of Training
Overseas Training/Course Yes
Name of Overseas Training/Course Country of Overseas Training/Course Duration of Overseas Training/Course Institution of Overseas Training/Course Supervisor of Overseas Training/Course
Fellowship in Neurointervention Yes
Duration of Fellowship Supervisor of Fellowship Institution / Hospital of Fellowship
Membership State Full MembershipAssociate MembershipHonorary Membership
