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NGO (fields marked with
*
are mandatory)
Name of NGO:
*
Enter name of NGO
Enter Characters Only between 3 to 100
Address:
*
Enter address
Enter Characters Only between 3 to 200
State:
*
--Select--
Select state
District:
*
--Select--
Select district
Pin Code:
*
Enter pincode
Pin code must be 6 numeric digits
Landline Number:
*
-
Enter STD Code
Enter Landline Number
Enter valid STD code from 3 to 5 digits
Enter valid LandLine number from 6 to 10 digits
Authorized Signatory:
*
Enter Authorized Signatory
Enter only characters between 3 to 100 with (. -)
Designation:
*
Enter Designation
Only Character between 3 to 100 with (. -)
Mobile:
*
Enter mobile number
Enter Only 10 digit
Email ID:
*
Tips:abc@gmail.com
Enter Email ID
Enter valid Email-ID
Verification code:
*
Enter verification code
Treatment Centre (fields marked with
*
are mandatory)
Name of Treatment Centre:
*
Enter name of treatment centre
Enter Characters between 3 to 100 with(.)
Address:
*
Enter address
Enter AlphaNumeric between 3 to 200 charcter with (.\-@#_,)
State:
*
--Select--
Select state
District:
*
--Select--
Select district
Pin Code:
*
Enter pincode
Pin code must be 6 digits
Landline Number:
*
-
Enter STD Code
Enter Landline Number
Enter valid STD code between 3 to 5 degit
Enter valid LandLine Number between 6 to 10 degit
Authorized Signatory:
*
Enter Authorized Signatory
Enter only characters between 3 to 100 with(. -)
Designation:
*
Enter Designation
Only Character between 3 to 100 with(.)
Mobile:
*
Enter mobile number
Enter 10 digit Mob Number
Email ID:
*
Tips:abc@gmail.com
Enter Email ID
Enter valid Email-ID
No. of Bed in treatment centre:
*
Enter No. of Bed
Enter Only Numeric
Types of treatment:
*
Enter Treatment Type
Enter Only Characters between 3 to 200 with (.-)
Verification code:
*
Enter verification code
NISD
NGO
Treatment Centre
Select NISD or NGO or Treatment Centre