Indian Medical Association.
Coimbatore
Application for Life Membership - Single/ couple
NAME : DR / MRS……………………………………………………………………………………………..
Designation: ……………………………………………………………….. Institution: ………………………………………………………….
Medical Qualification: ……………………………………………….. Specialty:……………………………………………………………
I hereby promise to abide by the rules , regulations and bye-laws of the Coimbatore branch of Indian
Medical Association.
Place:…………………………………………….. Date: ……………………………………………..
Birth Day : ………………………………… Wedding Day :……………………………………
Spouse(Working/House wife) details: :……………………………………………………………………………………………………….
Children: ……………………………………….
Wish to be Communicate through MOBILE PHONE/ SMS/ E MAIL/ POST *
Special interest in: research/teaching/academics /to attend IMA camps Etc .
Signature:………………………………………….
Requirements
1. Passport Size Photo 2 Nos.
2. Degree Certificate Xerox 2 Nos. Self attested
3. Medical Council Registration certificate Xerox 2 Nos. Self attested
4. Aadhar Card Xerox 2 Nos Self attested
5. Cheque for (Rs.24,000/-for Single or (Rs.36,000/- for Couples) in
favour of“Indian Medical Association, Coimbatore”
6. Cheque for Minimum Rs.1,000/-(for single) Rs.2,000/- (for Couples) in the name of
“CIMACT” or “Coimbatore IMA Charitable Trust”.
7. For CME Cr.Hours Rs.750/- (Per person) “Indian Medical Association, Coimbatore”
(If required by the member)
Cheque No:………………. Date:………….. Bank:…………………….Rs……...……..
Cheque No:……………… Date:………….. Bank:…………………….Rs……...……..
Cheque No:………………. Date:……..….. Bank:…………………….Rs……...……..
for Office use :
Receipt No.: 1)………………….. 2)………………….. 3)……………
INDIAN MEDICAL ASSOCIATION
I.M.A. HOUSE, INDRAPRASTHA MARG, NEW DELHI – 110 002.
Tel. +91-11-2337 8680, 2337 0473; Fax : +91-11-2337 9470, E.mail :
[email protected] MEMBERSHIP APPLICATION FORM
Annual / Life / Direct Membership Application Form
(All details to be filled in Block Letters)
Member’s Signature
Membership Proposed by Dr. ________________________ IMA Hqrs. Membership No. ______________________
To
The Honorary Secretary General, IMA
IMA House, I.P. Marg, New Delhi – 110 002.
Dear Sir,
I hereby apply to be enrolled as a member of the Indian Medical Association as ________________ member through
Local Branch _______________________________under the TAMIL NADU State / Territorial Branch of IMA.
Member’s Name as per MC / SMC Certificate : IN BLOCK LETTERS) : ______________________________________
___________________________________________________________________________________________
Father’s / Husband’s Name : _________________________________________ Date of Birth : ____ / ____ / ________
Address (Permanent / Correspondence) ______________________________________________________________
___________________________________________________________________________________________
______________________________________________________________________ Pincode : ____________
Clinic / Hospital Address ________________________________________________________________________
___________________________________________________________________________________________
Mobile No. _____________________________ Tel. (R) _______________ Tel. (Clinic/Hospital) _______________
E.mail ID ______________________________________ Aadhar No. ____________________ (enclose xerox copy)
QUALIFICATION M.B.B.S. (1) (2) (3)
COLLEGE
UNIVERSITY
Designation (Practice / Job) : _____________________________________________________________________
Registration Details : (Photocopy of Registration Certificate to be enclosed with IMA Hqrs. Form)
Registration No. of Medical Council of India / State Council ____________________________ Date : _____________
Service (details) : _____________________________________________________________________________
I declare that I am registered with MCI / State Medical Council, I certify that all
details / documents furnished are true. If my statement is found to be incorrect Date : __________
my membership would stand to be cancelled and the fee paid by me to all
sections of IMA will be liable to be forfeited by them. I hereby give undertaking
that I shall abide the Rules and Regulations of IMA. Place : __________ Signature of the Applicant
Certified that I have verified the qualification and registration of the applicant
and his eligibility as per rules of IMA for being enrolled as member of the Indian
Medical Association. Forwarded to the Hony. Secretary General along with Signature & Stamp of
HFC. Hony. Secretary, Local Branch
Forwarded to IMA Hqrs. along with HFC on ________________ Received at IMA Hqrs. along with HFC on __________________
Membership confirmed on ______________________________
Signature & Stamp of Dr. N.R.T.R. THIAGARAJAN
Hony. State Secretary, IMA TNSB Signature & Stamp of Hony. Secretary General
NB : The Local Branch Secretary will keep a photocopy of this form & forward the original form to State / Terr. Branch Secretary along
with Admission Fee & HFC and the State will also retain a photocopy of this form & send the original form along with Admission Fee
and HFC to IMA HQs. for proper record maintaining. The journal office will be informed by the Hony. Secretary General by providing
addressograph lists to JIMA.
Membership will be commence only after it is approved and confirmed by the Hony. Secretary General, IMA (HQs.)
