Title *

Full Name of Vice Chancellor/Director *

University/Institution Name * -Select- [AGRA-DBRAU] Dr. Bhimrao Ambedkar University, Agra [GORAKHPUR-MMTU] Madan Mohan Malviya University of Technology, Gorakhpur [LUCKNOW-KGMU] King George’s Medical University, U.P., Lucknow

Date of Birth *

Gender * --Select Gender-- Male Female Transgender

Email ID *

Mobile Number *