<%@ Page Language="C#" AutoEventWireup="true" CodeFile="Register_Medical_stores.aspx.cs" Inherits="Register_Medical_stores" %> <%@ Register Assembly="AjaxControlToolkit" Namespace="AjaxControlToolkit" TagPrefix="cc1" %> CITIZEN FORCE FOUNDATION FOR CITIZENS

Registrations will be commenced soon........

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Medical Store Registration

Medical Store Registration
Use dedicated Mobile for Medical Store Registration(do not use your Personal Mobile as it will prevent your registration in your personal category)
 
Your Medical Store Details, Services, Contact Number & Availability Times etc., will be displayed in "Services->Doctors->Medical Stores In My Area" by default.
In case, you do not wish to display the same BUT requires only personnel protection under Citizen Category, please UNCHECK the box here.
YOU CAN EDIT FROM TIME TO TIME THE INFORMATION PROVIDED HERE IN CERTAIN FIELDS AT ANY TIME THROUGH "LOGIN"
<%----%> <%----%> <%----%> <%----%> <%----%>
Pincode*
 :
State
 :
<%----%>
District
 :
<%----%>
Mandal / Taluk*
:
Post Office Name*
 :
*PIN CODE :
MEDICAL STORE NAME* :
Address of the Medical Store :
City / Town / Village :
Land Mark To Reach You Easily :
Locality / Area :
Street Name :
Ward / Division Number :
House Number :
Buliding Name :
Medical Store's Emergency Contact Number : Land line:  -   Mobile: +91-
Contact Pharmacist /Person Name :
Email address :
Confirm Email address : <%----%>
Door Delivery Available : YES NO
Availability :
Days Timings(Eg: 24 Hours, 9AM-12NOON, 4PM-9PM ETC...)
*Dedicated Mobile number (This will be your Login ID and to receive/retrieve forgot password) : +91-(Password will be sent to this mobile)
*Conform Mobile number : +91-
Do you wish to a Primary Volunteer? :
Yes No
Do you wish to disclose Your Identity as a Primary Volunteer? :
Yes No
BLOOD GROUP*
 :

Upload Photo :
Are you interested in BLOOD DONATION in case of emergency to anyone? [Please consider to say YES: Humanity is Godliness]
 :
Date & Time
 :
Security Code :
Enter Security Code* :
Form Filled By* :
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