INDIAN ORTHODONTIC SOCIETY

STUDENT LIFE MEMBER ONLINE APPLICATION

Documents to be Attached Passport Size Photograph Attested true copy of B.D. S. Degree Certificate Attested true copy of D.C. I. Reg. Certificate certificate from college certificate format Membership fee Payment Method Online Payment For Membership fee of Rs 6343(including Bank Charges and Service Tax)
Name (as in the records):*
Website
Email:*
Mobile:*
Fax with code
Nationality:*
Blood Group
D C I Reg. No. and State:*
Date of birth:*
Wedding Anniversary
Degree	Year	Institution	University
BDS :*/
Address – College: (which the applicant is doing MDS):*
Address:*
Street Name/Area:*
District:*
State:*
Pin Code :*
STD Code:*
Tele. No:*
Address – Permanent:
Address:*
Street Name/Area:*
District:*
State:*
Pin Code :*
STD Code:*
Tele. No:*
Address – Residence:
Address
Street Name/Area:
District
State
Pin Code
STD Code
Tele. No
Name of Spouse
Birth Date
Name of Children with age:
age:
Any Other Details (Memberships, Fellowships, Awards etc.)
Payment Mode:	Online Demand Draft(DD)
DD NO:

Documents to be Attached

The above furnished informations/testimonials are true to the best of my knowledge. I here by agree to abide by the rules and regulations of the Indian Orthodontic Society.