New Member Registration

Member Information

Member Type: *

Member Number:

Enter your member number, if you have.

Personal Information

Name: *

Enter Your Full Name

Username: *

Between 3 and 20 charecter, latter and number

Password: *

Retype Password: *

E-mail Address : *

Must be a valid email address, e.g: info@orlhnsbd.org

Phone Number : *

10 or More Charecter, numbers and dashes only, eg: 01-045-5657

Gender: *

Date of birth: *

Marital Status: *

Address:

Division: *

District: *

Thana: *

Professional Information

Specialist:

Designation:

Hospital/Clinic/Institute Name:

Hospital/Clinic/Institute Phone:

Hospital/Clinic/Institute Address:

Chamber Name:

Chamber Phone:

Chamber Address:

Qualification Information
Sl.DegreePassing YearInstitute/College/University
1
2
3
4
5
Others Information

Field of Special Interest:

Member of any other society:

Number of publication in the indexed Journal:



Security Image: *

Enter the word that you see in image

 

Note: Field Marked with * are required.