IMA Cochin - Member Register

MEMBERSHIP APPLICATION FORM

Annual / Life / Direct Membership Application Form

* Membership Type

* Name

* Sex

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* Branch

* Fathers / Spouse Name

* Date of Birth

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* Permanent Address

* Communication Address (Same as above)

* Clinic / Hospital Details

*Registration details of Medical Council of India/State Council

* Upload Registration Document

Proposed By (Optional)

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 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 by the Rules and Regulations of IMA

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The Indian Medical Association (IMA) is a national organization of doctors practicing Modern Scientific System of Medicine in India, which caters the interest of doctors as well as the well-being of the community at large.

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Address

Address:: IMA HOUSE STADIUM LINK ROAD, PALARIVATTOM P O COCHIN-682025
Reception:0484-2835000
Room reservation: 9388222421
Front office manager: 9388236677
Sales manager: 9544429933
Email:reservations@imahouse.in

MEMBERSHIP APPLICATION FORM

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