INDIAN DENTAL ASSOCIATION TAMILNADU STATE BRANCH

CARE AND CONCERN

FAMILY SECURITY SCHEME

(Please fill all information in Capital Letters)

PERSONAL DETAILS

Name

IDA ID

Age

Non Refundable Deposit

GST

Annual Fees

Total Amount

Address

Telephone (with STD Code)

Qualification

IDA Local Branch

NOMINEE DETAILS

Nominee Name

Address

Relationship of the Nominee

Membership Type

ANNUAL LIFE (IDA Life Members can only Join as Life Members in Care & Concern)

PHOTOGRAPHS

Dental Council Registration No.

State

Name of the father

Name of the mother

SIGNATURE

DECLARATION

I hereby declare that the information given above is true. I am aware of the rules and regulation of family security scheme of IDA Tamilnadu- * Care and Concern and I will abide by it.

Date