Membership Application
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01. Name : Dr. Mr. Ms. (Surname) (First Name) (Middle Name) I want my name to be printed in the Membership Certificate as : 02. Membership Category Applied For : Active Life Active Annual Associate Life Student Member         03. Address :    Address for mailing: Office / Residence   a. Office/ College/ Hospital : (Student Member can give the College Address)   City: State: Pin:   Tel No: Mob No: Fax No:    E-Mail:   b. Residence:    Pin: Tel No: 04. Date of Birth : 05.  Nationality : 06. Marital Status : Single / Married 07. For Student Membership: Year Ist Year IInd Year IIIrd Year   Course MDS D.Hyg D.Mech MDS Branch: (Resident bonafide certificate from college to be attached by all) 08. Qualification :       Degree Year College / University a. Graduate b. Postgraduate c. Others 09. Dental Council of India Registration No. of  state. 10. Field of Practice : 11. Undergone / not undergone Training in Oral Implantology. Details of Training :   a. Lecture / Demonstration / Hands-on: b. Duration / Date / Venue / Teacher: c. System: 12. System used in practice : 13. Presentations / Publications made: 14. Member of : (Professional bodies) 15. Membership Fees : Type of Membership Enrollment Fee Annual Fee Life Membership Fee For outstation Cheques add Total payable (to be entered) Ordinary Membership  (Active & Associate) Rs. 100/- Rs. 800/- - Rs. 100/- Life Membership  (Active & Associate) Rs. 100/- - Rs. 4000/- Rs. 100/- For Overseas: Life Membership  (Active & Associate) US$ 10 - US$ 200 - Student Membership (one year only) Rs. 50/- Rs. 250/- - Rs. 100/- (For Annual Membership fees are valid from 1st April to March 31, for Student Membership fees are valid from 1st July to 30th June irrespective of the month of joining). You can deposit cash in any branch of Bank of Maharashtra as per the following details : Title of account : Indian Society of Oral Implantologists Account Number : Saving Bank - No. 20002169228 Branch address : T.H.Kataria Marg, Mahim, Mumbai 400016   Payment Details: Rs. / US$ in  Cash / by Cheque / by Demand Draft No. dated , drawn from in favour of the "INDIAN SOCIETY OF ORAL IMPLANTOLOGISTS" payable at Mumbai. a) If deposited cash in the any branch of Bank of Maharashtra, please give details of Branch Name and date of deposit b) If you sent the cheque or DD to the Secretariat please give details of Courier Company or Postal details

Warning!: Incomplete applications will be rejected. Please do not misuse this form. You are tracked.
 

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