Application for Membership

General Information

Photo*

Title*

First name*

Middle Name

Last Name*

Pref Name*

Personal Information

DOB*

Gender

Marital Status

Blood Group

Spouse Name

Spouse Dentist

Yes

No

Children

Spouse A Member OF IDA

Yes

No

Educational Qualification

UG Qualification*

University

College*

Year Of Passing*

PG Qualification

University

College

Year Of Passing

Home Address

House No*

Area

City*

State*

Pin code*

Contact Information

Email* Enter Valid email

Alter Email Enter Valid Alter Email

Phone Number* Enter Valid Phone Number

Land Line Number

Fax No

Practice Information *

Please Select practice

General Practice

Pediatric Dentistry

Oral Medicine & Radiology

Endodontist

prosthodontics

Oral Pathology & Microbiology

Prosthodontics

Oral & Maxillofacial Surgery

Public Health Dentistry

Orthodontics

Others

Subscription *

Please Select subscription amount

Membership Fees (includes subscription fees, activity fees and service tax)

Annual New : ₹ 2000/-

Annual Renewal : ₹ 1800/-

Life Member (valid for life) : ₹ 19500/-

BANK DEPOSIT / ONLINE BANKING to ICICI BANK A/C No: 602801119067 AlcName: "IDAMADRAS BRANCH" IFSC Code: ICIC0006028 Branch: Alwarpet, Chennai.

Declaraion *

Please agree

By becoming an IDA member / submitting this application form. I agree hereby to receiving SMS and email messages, reminders, information from IDA about membership. Activities, Conferencesand Exhibitions and Continuing Dental Education programmes .

I declare that I have read the details of the IDA 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 (This does not include specialty societies.) in any area & have not been convicted by any court of low. I am not engaged in any activity detrimental to the interest of any association. I solemnly declare that the contents of this application form are correct to the best of my knowledge and information. I agree that if anything contained here is found to be false, my membership if Indian Dental Association is liable to be cancelled immediately.