IDA Membership Application

Type of Membership

Annual

1 year membership

Silver

3 year membership

Gold

5 year membership

Life

Lifetime membership

General Information

Title

Last Name

First Name

Middle Name

Preferred Name (for mailing)

Personal Information

Date of Birth

Gender

Male Female

Marital Status

Single Married

Blood Group

Name of Spouse

Is your Spouse a Dentist?

Yes No

Number of Children

Is your Spouse a Member of IDA?

Yes No

Educational Qualification

Graduation

University

Institute

Year of Passing

Post Graduation

University

Year of Passing

Specialization

Registration Number

State

Practice Information

Type of Practice (Select all that apply)

General Practice

Endodontics

Periodontics

Orthodontics

Pediatric Dentistry

Prosthodontics

Oral & Maxillofacial Surgery

Affiliation

Institute / Hospital

Designation

Mailing Address

Preferred Mailing Address

Office Address 1 Office Address 2 Home Address

1. Office Address

Practice Name

Address

Area

City

District

Taluka

Pin Code

State

Tel No. 1

Tel No. 2

Fax No.

Mobile No.

Office Timing

Email Address 1

Email Address 2

2. Office Address

Practice Name

Address

Area

City

District

Taluka

Pin Code

State

Tel No. 1

Tel No. 2

Fax No.

Mobile No.

Office Timing

3. Home Address

Address

Area

City

District

Taluka

Pin Code

State

Nominee Details (for IDA's National Social Security Scheme)

Title

Last Name

First Name

Middle Name

Age

Relation

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 agree hereby to receiving sms and email messages, reminders, information from IDA about Membership, Activities, Conferences, & Exhibitions and continuing Dental Education

I Declare that I have read all the details of the IDA constitution, Bye-Laws, NSS Scheme - Rules & regulations, 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 my area & have not been convicted by any court of law. 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 of Indian Dental Association is liable to be cancelled Immediately.

(New Members must attach supporting documents)

Signature

Date