ISOI - Indian Society of Oral Implantologists- www.isoimplant.com

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Online Membership Submission Form »

01. Name :

(Surname) (First Name) (Middle Name)

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: 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

Enclosed 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.

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

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