Institutional Membership Form
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Institution Name*
Institution Type*
-- Select --
Ayurvedic College
Drugs Manufacturer
Ayurvedic Store
Herbs Grower
N.G.O.
Ayurvedic Raw Drugs Seller
Panchkarma Center
Ayurvedic Hospital
Address of Institution* (Address to be printed on download certificate)
State* (Institution)
-- Select State --
Andhra Pradesh
Arunachal Pradesh
Assam
Bihar
Chhattisgarh
Goa
Gujarat
Haryana
Himachal Pradesh
Jharkhand
Karnataka
Kerala
Madhya Pradesh
Maharashtra
Manipur
Meghalaya
Mizoram
Nagaland
Odisha
Punjab
Rajasthan
Sikkim
Tamil Nadu
Telangana
Tripura
Uttar Pradesh
Uttarakhand
West Bengal
Andaman and Nicobar Islands
Chandigarh
Dadra and Nagar Haveli and Daman and Diu
Delhi
Jammu and Kashmir
Ladakh
Lakshadweep
Puducherry
District* (Institution)
-- Select District --
Year of Establishment*
Owner's Details
Title*
Mr.
Mrs.
Dr.
Owner Name*
Relation*
S/O
D/O
W/O
Father/Husband Name*
DOB*
Day
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Year
Contact Information
Permanent Address*
Permanent address is same as Address of Institution
City*
State* (Personal)
-- Select State --
Andhra Pradesh
Arunachal Pradesh
Assam
Bihar
Chhattisgarh
Goa
Gujarat
Haryana
Himachal Pradesh
Jharkhand
Karnataka
Kerala
Madhya Pradesh
Maharashtra
Manipur
Meghalaya
Mizoram
Nagaland
Odisha
Punjab
Rajasthan
Sikkim
Tamil Nadu
Telangana
Tripura
Uttar Pradesh
Uttarakhand
West Bengal
Andaman and Nicobar Islands
Chandigarh
Dadra and Nagar Haveli and Daman and Diu
Delhi
Jammu and Kashmir
Ladakh
Lakshadweep
Puducherry
District* (Personal)
-- Select District --
Pin Code*
Mobile*
WhatsApp*
Email*
Password*
Other Information
Website
Online
Cash
Cheque
Logo*
File size must be less than 5 MB.
Reference*
(Please provide the name and contact number of any VAP member or Office bearers known to you.)
Reference Name
Reference Phone
Submit & Pay Now
Membership Fee: Rs. 2500 only