Indian Medical Association Uttaranchal State Branch..

Member Application Form

Membership Proposed by Dr.*

IMA HQs. Membership No.*

Type of Member*

Local Branch*

State/Territorial Branch*

Personal Details

Member's Name (as per MCI/NMC/SMC Certificate)*

Father's/ Spouse's Name*

Age*

Date of Birth*

Permanent Address*

Correspondence Address*

Clinic/Hospital Details

Clinic/Hospital Address*

Mobile No.*

Tel. (R)

Tel. (W)

Email ID*

Aadhaar No.*

Qualification Details

QUALIFICATION	M.B.B.S.*	Post Graduation	Super Speciality
COLLEGE
UNIVERSITY
YEAR OF PASSING

Designation*

Registration No. of NMC /State Medical Council*

Registration Date of NMC /State Medical Council*

Upload Registration Certificate*

Allowed formats: PDF, JPG, PNG & SIZE UPTO 1 MB

Upload Photo*

Allowed formats: JPG, PNG & SIZE UPTO 1 MB

Upload Signature*

Allowed formats: JPG, PNG & SIZE UPTO 1 MB

Declaration

I declare that I am registered with SMC/NMC/MCI certify that all documents and documents furnished are true. If my statement is found to be incorrect my membership would stand to be cancelled and fee paid will not be refunded. I shall abide by the rules and regulations of IMA.