NIIM Dispensary Practitioner Registration Form

Name(Required)

First Last

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Email(Required)

Phone(Required)

Clinic name and address(Required)

Association & Member no.(Required)

Copy of qualification

Max. file size: 10 MB.

Please attach copy of qualification or confirmation enrolled in clinic if 4th year student.

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