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    01 IMA Membership Application Form

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    drrajak99
    This document is a membership application form for the Indian Medical Association (IMA). It requests information such as the applicant's name, address, qualifications, registration details, and proposes endorsement by a current IMA member. The applicant agrees to abide by IMA rules and regulations if accepted as a member. Local and state IMA branch secretaries are involved in verifying the application and applicant's eligibility before forwarding to IMA headquarters for final confirmation and approval of membership.

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    01 IMA Membership Application Form

    Uploaded by

    drrajak99
    32 views1 page
    This document is a membership application form for the Indian Medical Association (IMA). It requests information such as the applicant's name, address, qualifications, registration details, and proposes endorsement by a current IMA member. The applicant agrees to abide by IMA rules and regulations if accepted as a member. Local and state IMA branch secretaries are involved in verifying the application and applicant's eligibility before forwarding to IMA headquarters for final confirmation and approval of membership.

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    This document is a membership application form for the Indian Medical Association (IMA). It requests information such as the applicant's name, address, qualifications, registration details, and proposes endorsement by a current IMA member. The applicant agrees to abide by IMA rules and regulations if accepted as a member. Local and state IMA branch secretaries are involved in verifying the application and applicant's eligibility before forwarding to IMA headquarters for final confirmation and approval of membership.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as pdf or txt
    32 views1 page

    01 IMA Membership Application Form

    Uploaded by

    drrajak99
    This document is a membership application form for the Indian Medical Association (IMA). It requests information such as the applicant's name, address, qualifications, registration details, and proposes endorsement by a current IMA member. The applicant agrees to abide by IMA rules and regulations if accepted as a member. Local and state IMA branch secretaries are involved in verifying the application and applicant's eligibility before forwarding to IMA headquarters for final confirmation and approval of membership.

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    of 1

    INDIAN MEDICAL ASSOCIATION

    I.M.A. HOUSE, INDRAPRASTHA MARG, NEW DELHI - 110 002.


    Tel. +91-11-2337 8680, 2337 0473; Fax : +91-11-2337 9470, E.mail : inmedici@vsnl.com

    MEMBERSHIP APPLICATION FORM


    Annual / Life / Direct Membership Application Form
    (All details to be filled in Block Letters)
    Member’s Signature
    Membership Proposed by Dr. ______________________ IMA Hqrs. Membership No. _____________________
    To,
    The Honorary Secretary General, IMA
    IMA House, I.P. Marg, New Delhi - 110 002.
    Dear Sir,
    I hereby apply to be enrolled as a member of the Indian Medical Association as ______________ member
    through Local Branch ________________________ under the TAMIL NADU State / Territorial Branch of IMA.
    Member’s Name (as per MCI/SMC Certificate; IN BLOCK LETTERS) :____________________________________
    ________________________________________________________________________________________________________________________________________________________
    Father’s / Husband’s Name : ____________________________________ Date of Birth : ____ /____ /________
    Address (Permanent / Correspondence) _________________________________________________________
    ________________________________________________________________________________________________________________________________________________________
    Clinic / Hospital Address : ____________________________________________________________________
    ________________________________________________________________________________________________________________________________________________________
    Mobile No. __________________________ Tel. (R) _________________ Tel. (Clinic / Hospital) _____________
    E.mail ID _______________________________________________ Fax No. ___________________________
    QUALIFICATION M.B.B.S. (1) (2) (3)
    COLLEGE
    UNIVERSITY
    Designation (Practice / Job) : _________________________________________________________________
    Registration Details : (Photocopy of Registration Certificate to be enclosed with IMA Hqrs. Form)
    Registration No. of Medical Council of India / State Council ________________________ Date : ____________
    Service (details) : __________________________________________________________________________
    I declare that I am registered with MCI / State Medical Council. I certify that
    all details / documents furnished are true. If my statement is found to be Date : _________
    incorrect my membership would stand to be cancelled and the fee paid by me _____________________
    to all sections of IMA will be liable to be forfeited by them. I hereby give
    undertaking that I shall abide the Rules and Regulations of IMA.
    Place : _________ Signature of the Applicant

    Certified that I have verified the qualifications and registration of the applicant
    and his eligibility as per rules of IMA for being enrolled as member of the
    Indian Medical Association. Forwarded to the Hony. Secretary General along Signature & Stamp of
    with HFC. Hony. Secretary, Local Branch
    Forwarded to IMA Hqrs. along with HFC on __________ Received at IMA Hqrs. along with HFC on __________
    Membership confirmed on _____________________
    __________________________________
    _____________________________________
    Signature & Stamp of Hony. State Secretary
    Signature & Stamp of Hony. Secretary General
    NB : The Local Branch Secretary will keep a photocopy of this form & forward the original form to State / Terr. Branch Secretary along
    with Admission Fee & HFC and the State will also retain a photocopy of this form & send the original form along with Admission Fee
    and HFC to IMA HQs. for proper record maintaining. The Journal office will be informed by the Hony. Secretary General by providing
    addressograph lists to JIMA.
    Membership will be commence only after it is approved and confirmed by the Hony. Secretary General, IMA (HQs.)

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