National Integrated Medical Association

Members Application Form

(Please fill in Triplicate (1) for Central Office (2) for State Branch Office & (3) for District
/ Local Branch Office.)
To,
The Hon General Secretary.
National Integrated Medical Association
Dear Sir, I hereby apply for the Membership / Direct - Membership / Life - Membership
of NIMA
through_________________________________ Branch ___________________State.
I am
sending my subscription Rs._______ by ____________ I have carefully read the
memorandum
Rules and Bye-laws of the Association and agree to abide by them Please enrol me as
a Member of NIMA. My
particulars are given below.
&nbspYour's faithfully,
&nbsp____________
(Signature of applicant)
Date :_____________
1. .Full name (beginning with surname
and in block
letters)___________________________________________________________
2. Address Residence
:__________________________________________________________
___________________________________________Phone
No._______________________
Dispensary / Room
:__________________________________________________________
___________________________________________ Phone
No._______________________
3. Date of Birth________________________

4. Single/Married/Widower/Widow_____________
5. Academic Qualifications (with names of Examining Bodies and dates of acquiring
them.)
1._______________________________________________________________
____
2._______________________________________________________________
____
3._______________________________________________________________
____
6. Registration Number _______________________Date of
Registration__________________
Name of the Board / Council of Registration
________________________________________
7. Professional Status :- (Private Practitioner / Teacher etc.)
______________________________
a. Practitioner - Yes / No.
Hospital Attachment to :
________________________________________________________
In what capacity :
___________________________________________________________
__
b. In Service : Yes / No. Designation :
____________________________________________
Name of Employer
:________________________________________________________
c. Concerned with Medical Education as a teacher - Yes / No.
Name of the
Institution:___________________________________________________
___
Designation
:__________________________________________________________
___

d. Research worker - Yes - No. Designation

:_______________________________________
Name of the Institution
:______________________________________________________
e. Any scientific papers published ? State titles :
_____________________________________

8. Were you a Member of NIMA before?

Yes/No._________________________________________
If so, trrough which Branch?
_______________________________________________________
9. If Yes when was the membership discontinued and for what reasons?

For Office Use

[to be filled by the secretary, District / Local Branch]
1. Forwarded to the Hon. Secretary.
[with State & Central Share Rs. _______________]
Place :
____________________________[Sign.]___________________________
Date : _______________________Hon Secretary
_______________________________ Branch

[To be filled by the Secretary, State Branch]

2. Forwarded to the Hon. Gen Secretary NIMA [with Central Share Rs.
______________________]
Place : ___________________[Sign] ________________________
Date :______________________ Hon. Secretary
________________________State Branch

3. RECEIVED at the Central Office on _________________________ from

__________________
Central share Rs. ______________________________ Received / not received.
Membership Accepted / Rejected, for
_______________________________________________
Membership No. ______________________________ File
___________________
Place : ____________________________
Date : _____________________________
________________________________
Signature of the Hon. Gen. Secretary
National Intergrated Medical Association (Central Council)