Application-form-for-membership- IMPA

Name Dr/Dr(Mrs) *

Qualifications

Type of Practice

SLMC Reg.No.

Office Address *

City

Residence Address

Office Phone -Contact No

Residence Phone No

Mobile no

Email address

Fax no

Proposed by

Seconded by

Independent Medical Practitioners Association of Sri Lanka, Bank of Ceylon , Branch - Independence Square ,A/c no 2323090, Swift code BPEYLKLX. • Life Membership – A fee of Rupees of 5000.00 (inclusive of Rs. 1000/- for Registration). • Ordinary Membership – A fee of Rs. 1000.00 paid annually being the cost of Ordinary Membership plus Rs.1000/- as Registration fee, and a total fee of Rs.2000.00.

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 )

SLMC Reg.NoIf the answer is Yes - State

IMPA-SL