INDIAN MEDICAL ASSOCIATION GOES ECOFRIENDLY (IMAGE)

IMA State Headquarters, Anayara.P.O, Thiruvananthapuram - 695 029

Ph: 0471 2742211
Email: imageimaksbtvm@gmail.com

APPLICATION FOR AFFILIATION TO IMAGE

From (Full Postal address in block letters) Date :

SIJIN SIVANKUTTY , Mds

DR SIJINS FAMILY DENTAL CLINIC, CP/VI/85K

NEAR SARKARA TEMPLE SARKARA BYPASS ROAD, CHIRAYINKIL, TRIVANDRUM, KERALA

Pin: 695304 Ph: 09746314507 Mob: 9746314507

To
The Secretary
IMAGE, IMA, KSB
Anayara.P.O., Thiruvananthapuram-29
Ph: 0471-2742211

Dear Sir,

While furnishing the relevant details of our Healthcare institution overleaf we request that our institution may be affiliated to IMAGE.
One copy of the duly signed and sealed terms and conditions of IMAGE is also enclosed here with.

Yours Faithfully
Place : Trivandrum
(Seal) Signature

Date : 28-12-2021
(Name and designation)

Remittance details
Affiliation fee for Rs. 6000.00 encIosed by D.D. No. SBIN421362934584 dated 28-12-2021 of Sbi Bank Chirayinkil Branch
drawn in favour of IMAGE payable at Thiruvananthapuram.

Verification report

I have personally'verified the number of beds /dental chairs and details furnished overleaf are found to be correct.
 Signature...........................................................................
Dr......................................................................................
Dist.Representative, IMAGE:........................... District
President / Secretary,IMA..........................Branch

[ Overleaf ]

Details of Healthcare Institution

Name of Healthcare Institution: : DR SIJINS FAMILY DENTAL CLINIC

Address : DR SIJINS FAMILY DENTAL CLINIC, CP/VI/85K

NEAR SARKARA TEMPLE SARKARA BYPASS ROAD, CHIRAYINKIL, TRIVAND

India , PIN : 695304

Name of Municipality / Corporation / Panchayat : Chirayinkil Panchayat

District : Trivandrum

Ph. No. with STD code : 09746314507

Fax No. :

E-mail : sijinsijin170@gmail.com

Dental Institutions
Feature Count
No. of Dental chairs 1

Haematology /Biochemistry Lab

Microbiology Lab

Pathology

Other speciality lab

Contact person for communications : Sijin Mobile : 9746314507

Name of Segregation In-charge : Dr Sijin Mobile : 9746314507

Designation of Segregation In-charge : Mds 11509

Have you already started ?: Yes

Date of Starting : 19-11-2020

Whether the Building &

Infrastructure Completed ?: No

If there a provision for Safe & Secure

Storage of Biomedical Waste with easy
vehicle access in th HCE ?: No

Do you have IMA Membership ?: No

 Signature
(Seal)

(Name and designation)

FOR OFFICE USE ONLY

Affiliation fee of Rs....................received as per D.D. No... .............dated..................................for...............beds/dental chairs

@Rs...................Reciept No......................Date.............................

By.................................................................

Bed strength/dental chairs

Yes/No
checked Signature

Secretary , IMAGEIMA