Registration

Full Name (In English) *

Full Name (In Bangla) *

Email *

Mobile Number *

Gender *MaleFemaleother

Date of Birth *

NID Number *

e-TIN Number

Contact Address *

Holding No/Apartment *

Street *

Village/Thana *

Postal Code *

WhatsApp number (if different)

BMDC Registration Number *

MBBS Passing Year *

MBBS Institution *

Post-graduationMention Degree Name, Year & Institution [Leave empty if not present]

Current Affiliation *Designation, Working Place

Photograph *Upload a photograph of yourself with a plain background (file size less than 10 MB)

No file chosen

Payment Amount *Membership fee Tk. 500 Annual renewal fee Tk. 500

Payment Receipt

Upload screenshot of proof of payment

Merchant Name: Acute and Critical Care Physician Foundation Bangladesh (ACCPFB)

Bkash number: 01575094817

OR A/C

Name: ACUTE AND CRITICAL CARE PHYSICIANS FOUNDATION BANGLADESH

Bank: MUTUAL TRUST BANK PLC

A/C No: 1301000205569

Branch: Bashundhara City Branch, Dhaka

Upload 1 supported file: PDF or image. Max 10 MB.

No file chosen

Declaration *I hereby faithfully promise to abide by the Laws, Byelaws, Statutes and Regulations of the Acute & Critical Care Physicians Foundation Bangladesh, as they apply to the members, as from time to time modified, amended or re-enacted.I confirm that the information given on this form is true, complete and accurate and that no information requested, or other material information has been omitted.

Password *

Re write password *

Search site

Member Registration