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Student Registration Form

Student Membership Online Registration Form

Please Fill Your Details in the form given below.

Login Name

Password

Confirm Password

General Information			LastName	FirstName	MiddleName

	Pref Name	:

Personal Information	BirthDate	:		Blood Group	:
Personal Information	Gender	:

Educational Details	Graduation	:	PostGraduation	:
	University	:	University	:
	College	:	College	:

Contact Details

RESIDENCE ADDRESS

CITY

PIN

STATE

TEL NO

--
ISD-STD-Phone No.

MOBILE

-
ISD-Mobile No.

EMAIL

WEB

Please attach your photo

(Image size should be 150*80 and not more than 20 kb)

Student Members:-Rs. 1000/- for the tenure of the under-graduate course, irrespective of year of joining

Check / DD Number	:
Date/month/Year	:
Bank :	:
* Enrolment / Renewals can be made either at IDA HO / State / Local Branches. * Outstation Payment to be made by DD / Credit Card Only

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

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