Member Registration

IAP Membership Application Form

Applying for *

Personal Details

Title of the Applicant *

First Name of the Applicant

Middle Name of the Applicant

Last Name of the Applicant *

Application Type(Single/Couple Life) *

Please attach a stamp size photograph (3x2.5cms) with this application and file size of the image should be less than 2 MB:

For icard - File Upload(only JPG/PNG)*

Address Line 1 *

Please provide following information for Address proof(DL/Passport, Aadhaar, Govt approved id proof). File size of the image should be less than 2 MB:

File Upload(only JPG/PNG)*

State *

City *

Postal Pin *

country *

Registered Mobile No.(only 10 digits) *

Alternate Mobile No.(only 10 digits)

Registered Email *

Alternate Email

Office Telephone No.

Residence Telephone No.

PAN Card Number*

Please upload PAN card copy. File size of the image should be less than 2 MB:

File Upload(only JPG/PNG)*

Date of Birth *

Gender *

Male Female Perfer Not to say Other

Qualification

Highest Medical Qualification(for life and couple life pediatric PG degree and for associate MBBS degree) *

Name of the University*

State *

Qualifying Year (Ex - 1990) *

Upload Degree/Certificate (only JPG/PNG - Max 2MB) *

Medical council registration

Name of state where Medical Council/MCI/NMC registered*

Registration Year (Ex - 1990) *

Registration Number of the state Medical Council/MCI/NMC*

Upload Registration Certificate Of State Medical Council / Medical Council Of India (only JPG/PNG - Max size 2MB) *

IAP Branch

(IAP Dist./City/Local Branch and Zone will be auto selected based on IAP State)

IAP State Branch *

IAP Dist./City/Local Branch *

Zone *

Proposer Details

(Only Life members or Fellow Members can be a Proposer)

IAP membership no.* (ex - X/1234/X-1234) - USE ONLY CAPITAL LETTER

Below Details will auto generate on entering correct proposer membership number

Name of the Proposer*

Email of the Proposer*

Mobile of the Proposer*

City of the Proposer

State of the Proposer

Pincode of the Proposer

Seconder Details

(Only Life members or Fellow Members can be a Seconder)

IAP membership no.* (ex - X/1234/X-1234) - USE ONLY CAPITAL LETTER

Below Details will auto generate on entering correct seconder membership number

Name of the Seconder *

Email of the Seconder*

Mobile of the Seconder*

City of the Seconder

State of the Seconder

Pincode of the Seconder

Other Details

Anniversary Date

Emergency Contact number

Blood Group

Any Other Detail

I do hereby declare that all the information given above is true to the best of my knowledge and belief.
Please read all the details filled once again before submission. Submission of Application will not guarantee acceptance. Verification and Approval process will take around 30 days' time.

Category of Membership	Admission Fee	Membership Fee	Total Amount Payable
Life	Rs.500/-	Rs.9500/-	Rs.10,000/-
Associate Life	Rs.500/-	Rs.9500/-	Rs.10,000/-