A IAN SSOC IA

OF PH ON Y TI

THE INDIAN ASSOCIATION OF PHYSIOTHERAPISTS APPLICATION FORM FOR PHOTO ID CARD

OT SI

HERAPIST S

PLEASE NOTE :
1. 2. 3. 4. 5. 6. To be filled as per the I.A.P. Membership Certificate / Degree Certificate. Fill in Block Letter. Attach a copy of the I.A.P. Life Membership Certificate (for old members only). ID card issued for IAP life members only. IT takes 6 months to deliver photo ID card. Charges for Photo ID Card Rs. 300.

D IN

PASSPORT SIZE PHOTO

Contact Details : Name Dr. Physiotherapist Blood Group Date of Birth
D D M M Y Y Y Y

Sex : M (Not applicable for new members)

F

I.A.P. Registration Number Address

City / Town State Pin Code Email id Mobile No.

Specimen Signature

Rupees 300/- DD No.

Bank Name

Date

Please send your filled application to Dr. Anand Mishra Flat No. 202, Unique Park, 8 FF Scheme No. 54, Vijay Nagar, Indore - 452010 (M. P.) Mobile : +91 98272-52576 New members may enclose this form along with application form.

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