Application-form-for-membership- IMPA

Dr / Dr(Mrs.) /Prof *Name :-

Qualifications

Type of Practice

SLMC Reg.No

Office Address

Residential Address

Office Phone

Residence Phone No

Mobile no

Email address

Proposed by

Seconded by

Upload file - The Payment Receipt *

No file chosen

Date

Signature…

Is your spouse a Doctor ?YesNo

If the answer is yes / State – Name: Dr / Dr ( Mrs ) / Prof

SLMC Reg.NoIf the answer is Yes - State

IMPA-SL