Register - Academy of Global Education (AGE) - Healthcare Educational Programs in Bangalore

Personal Information

First Name *

Middle Name

Last Name

Gender *

Male Female Third Gender

Professional Title *

Other Professional Title *

Medical Registration No.

Hospital / Institution *

Department *

City *

Pin Code

State *

Address Line 1*

Address Line 2*

Contact Detail

Mobile Number *

Telephone Number (Optional)

Email *

Activity Requested

Select Course *

Mode of Payment

Select Payment Mode *

Bank Account Details :

Account Name : ACADEMY OF GLOBAL EDUCATION
Account Number : 1612606338
Back Name : KOTAK MAHINDRA BANK
IFSC Code : KKBK0008066
Account Type : CURRENT ACCOUNT
Branch : MG ROAD

Note : Kindly transfer the amount to the above account details to comfirm your registration.

"Transfer of Activity to other date OR Refund of Activity Fee is not Allowed."

* I have raed and understood the above statement and responsible for any balance due