LIS Academy Membership

Select Type of Membership*

Name Prefix*

First Name *

Last Name *

Designation *

D.O.B *

Select Gender *

Institution Name*

Institution Place

Residential Address *

Zipcode *

Nationality *

Country *

City *

State *

Phone (Landline with Country Code)*

Mobile Number*

Email address *

Alternate Email (preferably Gmail Account)

Upload your Passport size photo *
(Max 10 MB)

Application will be Rejected if the applicant passport size photo is not upload
(Any other photo will not be accepted)