Application For Membership
Please complete this application form legibly in all respects, using capital letters
Type of Membership
1. Annual:
Rs 1711/-
2. Annual - Renewal Membership: Rs 1357/-
3. Silver:
Rs 7139/-
4. If Annual member appying for Silver Membership: Rs 6785/-
5. Gold:
Rs 13924/-
6.
If Annual member applying for Gold Membership:
Rs 13570/-
Last Member ID
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General Information
Title
*
First Name
*
Middle Name
Last Name
*
Preferred Name( for mailing )
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Personal Information
Date Of Birth
*
(Example: Write simple as 26 02 1988 )
D:
M:
Y:
Blood Group
Sex
*
M
F
Marital Status
M
S
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Address
Address
*
City / Dist
*
Pincode
*
State
*
Call Number
*
Email Address
*
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Declaration
By becoming an IDA member, herewith I provide my consent to be a part of IDA's National Social Security Scheme.
By becoming an IDA member/submitting this application form, I hereby agree to recevie SMS, E-Mails, reminders & information from IDA about Membership, Activities, Conferences, Continuing Dental Education programmes, Publications & Catalogues.
ID Proof Upload (Pan card, Aadhar card, Driving Licence or Passport)
* (Max file size 5MB)
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