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IDA Membership Form

This document is an application form for membership in the Indian Dental Association. It requests information such as the applicant's personal details, education and qualifications, practice details, preferred mailing address, and payment details. The applicant must declare that they have read and agree to abide by the association's constitution, bylaws, code of ethics and will not engage in any detrimental activities. They must also not be a member of any parallel dental association. The form provides the addresses of the association's head office and local/state branches.

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Abhijit Lele
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701 views3 pages

IDA Membership Form

This document is an application form for membership in the Indian Dental Association. It requests information such as the applicant's personal details, education and qualifications, practice details, preferred mailing address, and payment details. The applicant must declare that they have read and agree to abide by the association's constitution, bylaws, code of ethics and will not engage in any detrimental activities. They must also not be a member of any parallel dental association. The form provides the addresses of the association's head office and local/state branches.

Uploaded by

Abhijit Lele
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Application for Membership


Please complete this application form legibly in all respects, using capital letters. Type of Membership General Information 1. Annual Title 2. Life Last Name 3. Direct 4. Affiliate First Name Middlle Name
Signature

Preferred Name (for mailing)

Personal Information

MM

DD

YY M

Sex F

Marital Status M S

Blood Group

Name of Spouse

Is your Spouse a Dentist

Number of Children

Is your Spouse a Member of IDA

Y Edu. Qualification

Graduation / University

Institute

Yr. of Passing

Post Graduation / University

Yr. of Passing

Specialisation

Regd. No.

State

Practice Information

Type of Practice:

General Practice Pediatric Dentistry

Endodontics Prosthodontics

Periodontics

Orthodontics

Oral & Maxilofacial Surgery

Affiliation Designation

Institute / Hospital Lecturer Oral Pathologist Dental Surgeon Asso. Professor Prosthodontist Others
1 Address 2 3

Professor Pedodontist

Dean Periodontist

Director Orthodontist

Mailing Address 1. Office Address

(Please indicate preference of mailing address) Practice Name Address

Area

City

Dist.

Taluka

Pin Code

State

Tel. No. 1

Tel. No. 2

Fax No.

Cell Number

Office Timing

Email Address

2. Office Address

Practice Name

Address

Address

Area

City

Dist.

Taluka Tel. No. 1

Pin Code Tel. No. 2

State

Fax No.

Office Timing

3. Home Address

Address

Area

City

Dist.

Taluka

Pin Code

State

Tel. No. 1

Tel. No. 2

Subscription

Subscription:
A) Annual Member: Admission fee (New) Rs. 300/Annual /Renewal fee - Rs.650/B) Life Member: Admission fee (New) - Rs.300/-. Life Membership fee (one time) Rs.10, 650/-

C) Affiliate member annual fee - US $100 (Payable only at IDA HO)

Cheque / DD Number

Date / Month

Year

Bank

Credit Card No.

* Enrolment / Renewals can be made either at IDA HO / State / Local Branches. * Outstation Payment to be made by DD / Credit Card Only.
Declaration
I declare that I have read through the details of the IDA Application Form, the Constitution, Bye-Laws, Code of Ethics & professional conduct and resolve to abide by them. I am not a member of any association functioning parallel to IDA in my area & have not been convicted by any court of law. (This does not include specialty societies). I am not engaged in any activity detrimental to the interest of any association. The information provided by me is true & I hereby submit my application for membership to IDA. (New members must attach supporting documents.)

Signature

Date: State Branch Address Local Branch Address

Office Use Only

IDA HO Address
Indian Dental Association Bombay Mutual Terrace, 2nd Flr. 534, Sandhurst Bridge, Opera House, Mumbai-400 007

Tel. : Fax :

022 2367 1515 022 2369 6655 022 2368 5613

Email : [email protected]

Date & Signature

Date & Signature

Date & Signature

Remarks

LA NTA SSO C DE
N

TI O IA

INDIA

HE AD

ICE OF F

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