PREFERABLY TYPE OR WRITE IN BLOCK LETTERS

Name      ____________________  _____________________ _____________________

                              ( Surname )                          ( Name )              ( Father’s/ Husband’s Name )

Date of Birth

Degrees

Mailing Address

Telephone :
Hosp. / Instit/ Clinic Address

Telephone :
Resi. Address

MEMBERSHIP DUES

LIFE : Rs. 4200 / - ORDINARY : Rs. 1000/- STUDENT : Rs. 800/- ASSOCIATE : Rs . 800/-

Curent Year ( Please enter amounts )

Life : _________________Ordinary : ____________________Student : ___________________Associate : ____________________ :

Enrollment fee ( Rs. 200/-) ( Not for Students ) __________________ Bank Fee Rs. 25(if outstation) _______________

NATURE OF PAYMENT

Cash : ___________M.O. : __________Cheque No. : _________D. Draft No.______________

Drawn on : _________________Branch : _________________Date :____________________

REMARK BY Secy./Treasurer (TOTAL PAYBLE FOR OFFICE USE ONLY)

Please make cheque/ DD ( A/C payee ) M.O. in the name of ‘ Indian Radiological & Imaging Association (state branch name) and mail it to your state secretariat or to the IRIA

Date Rept. : ___________Rept. Posted : ___________To Centre : _____________

DECLARATION

_______________________ __________________________ _______________________

             ( Surname )                                     ( Name )                                   ( Father’s Name )

am desirous of being elected Life / Ordinary / Student / Associate member of Indian Radiological & Imaging Association and agree. If elected , to conform in all respects to the rules & Bye-laws of the Association now existing or such rules and Bye-laws which may hereafter be made altered. I declare that , I am ( tick those applicable to you )

Fully qualified in Medical Radiology

Engaged solely in the practice of specialty of Radiology in one or more of its branches ( please mention below )

Date : Signature of applicant                               PROPOSED BY : ( Member )

Name ______________________________ Name _____________________________

Folio No. ___________________________ Folio No. _____________________________

Signature ___________________________ Signature

Address ____________________________ Address

RECOMMENDATION OF BRANCH SECRETARY

He / She fulfills the conditions and may be enrolled as – Life – Ordinary – Student – Associated member

Signature of Branch Secretary

FOR CENTRAL OFFICE USE ONLY