IDA Madras

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Online Registration Form

Membership Online Registration Form

Please Fill Your Details in the form given below.

Login Name

Password

Confirm Password

Type of Membership

Amount to be paid :

General Information			LastName	FirstName	MiddleName

	Pref Name	:

Personal Information	BirthDate	:	Blood Group	:
	Gender	:	Spouse	:
	Marital Status	:	Is Spouse Dentist	?

Educational Details	Graduation	:	PostGraduation	:
	University	:	University	:
	College	:	College	:
	Passing Year	:	Passing Year	:
	Regd. No.	:	State	:
	Specialization	:	Other Quali.	:

Practice Information		General Practice	Endodontist	Periodontist	Orthodontist
Practice Information		Pediatric Dentistry	Prodthodontist	Oral & Maxilofacial Surgery

Affilation

Institute/Hospital

Designation	Lecturer	Professor	Asso.Professor	Dean
	Director	Orthodontist	Oral Pathologist	Prosthodontist
	Peddontist	Periodontist	Dental Surgeon	Others

Contact Details

OFFICE ADDRESS

CITY

PIN

STATE

TEL NO

--
ISD-STD-Phone No.

FAX

--
ISD-STD-Fax No.

OFFICE EMAIL

RESIDENCE ADDRESS

CITY

PIN

STATE

TEL NO

--
ISD-STD-Phone No.

MOBILE

-
ISD-Mobile No.

PERSONAL EMAIL

WEB

Please attach your photo	:	(Image size should be 150*80 and not more than 20 kb)
Mode Of Payment	:
Total Amount Paid	:
Details of Payment (Online Transfer Number Or Cheque/DD Number or Branch Name)	:
Date of Payment	:

Note : Once you filled the above form, online facility to submit your all relevant scanned Documents are provided. Kindly use it to send your documents safe and faster.

Mail to:

Dr.V.Rangarajan
Indian Dental Association - Madras
Hon. Branch Secretary
230, Avvai Shanmugham Salai,
Royapettah, Chennai - 600 014,
Tamil Nadu, India
Mobile :   94440 71871
Phone   :   044-28133186
Fax        :   044-28131094
E-mail   :   info@idamadras.org
Web      : www.idamadras.org

Payment Method

You have to make DRAFT / CHEQUE in favour of "INDIAN DENTAL ASSOCIATION - MADRAS BRANCH" payable at CHENNAI, INDIA and send to the below address.
or
Deposit cash in our ICICI Bank Account, favouring "INDIAN DENTAL ASSOCIATION - MADRAS BRANCH" payable at CHENNAI. Account No.602801119067.

Indian Dental Association - Madras
Dr.V.Rangarajan
Hon. Branch Secretary
230, Avvai Shanmugham Salai,
Royapettah, Chennai - 600 014,
Tamil Nadu, India

Membership