INDIAN MEDICAL ASSOCIATION

IMA HOUSE, INDRAPRASTHA MARG, NEW DELHI-110002
Tel.: +91-11-2337009 (10 Lines), 23378819, 23378680, WhatsApp: +91-9999116376
Email: hfc@ima-india.org, hsg@ima-india.org

MEMBERSHIP APPLICATION FORM

Life/Direct Membership Application Form

(All details to be filled in Block Letters)

Photo

Member Personal Information

Membership Proposed By Dr.

IMA HQ Membership No

Member Name

Father's / Spouse Name

Age

Date Of Birth

Member Type

Local Branch

State / Territorial Branch

Mobile Number

Telephone (Residence)

Telephone (Work)

Email ID

Aadhaar Number

Permanent / Correspondence Address

Clinic / Hospital Address

Qualification Details

Qualification	College	University	Year Of Passing
MBBS
Post Graduation
Super Speciality

Professional Details

Designation (Practice / Job)

Registration No Of NMC / State Medical Council

Registration Date

Do You Have Professional Indemnity?

Yes No

If the member is also insured by any insurance company and a complaint is filed against him/her, KPPS undertakes to offer services of panel advocates for defence. If the member refuses the offer and chooses insurance company defence only, KPPS shall not have liability for the case outcome.

Upload Documents

Photocopy of Registration Certificate to be enclosed with IMA HQs. Form

Declaration

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

Applicant Details

Date

Name Of Applicant

Upload Signature

Certificate From Local Branch

Certified that I have verified the qualification, registration number and documents produced by the applicant and found to be correct. He / She is eligible as per rules and regulations of IMA for membership.

Date

Name Of Local Branch Secretary

Upload Signature

Upload Seal

Certificate From State Branch / Union Territory

Certified that I have verified the application form sent through local branch and found it to be correct. He / She is eligible for membership of IMA.

Date

Name Of State Branch Secretary

Upload Signature

Upload Seal

IMA Headquarters Confirmation

Received At IMA HQs Along with HFC On

Membership Confirmed On

Upload Signature & Stamp Of Honorary Secretary General

Important Notes

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 Honorary Secretary General by providing addressograph list to JIMA.

Membership will be commenced only after it is approved and confirmed by the Honorary Secretary General, IMA (HQs.)

*It is decided that now onwards if any Local Branches and State Branches after receiving membership form and membership fees (HFC+18% GST+ Any applicable tax by GOI time to time) from New Member and from Branches fail to submitted the same within a month to the IMA Headquarters office at New Delhi.