IMA MEMBERSHIP TRANSFER FORM :



INDIAN MEDICAL ASSOCIATION IMA AP STATE
APPLICATION FOR TRANSFER OF MEMBERSHIP
TO A DIFFERENT BRANCH WITHIN ANDHRA PRADESH

(XEROX MAY BE USED) (COUPLE MEMBERS TO APPLY SEPERATLY)

To
The Honorary State Secretary
IMA AP State, IMA Building
Isamia Bazar, Hyderabad-500 027
Ph: 040-24656378, Fax: 040-24738197

Through 1.Branch Secretary------------------------------------------------- (Sending Branch)

2.Branch Secretary------------------------------------------------- ( Receiving Branch)
Dear Sir,

I request you to transfer my membership from ------------------------------------------Branch(Sending Branch) to --------------------------------------Branch( receiving Branch) as ------------------------------------------------------------------------- (reasons).

Name of the Applicant for Transfer: Dr.------------------------------------------------------------------------

Life Membership No:-----------------------------------------------------------------------------------------------

Address --------------------------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------------------------
Tel:------------------------------------------- Mobile----------------------------------------------------------------

If Member of FBS No:----------------------------------------------------------------------------------------------

If Member of PP& W Scheme:-------------------------------------------------------------------------------------

If Member of APPA FSS No: -------------------------------------------------------------------------------------

Thanking you,
Member Signature

No Objection from Sending Branch.

The ---------------------------------------------- Branch (Sending Branch) has no objection to the above transfer. The member has no dues to their branch. We are enclosing the branch share of Life membership contribution (by D.D.No.---------------------------- in favour of Hony. Secretary------------------------------------------------ Branch (receiving)

Yours Sincerely

Hony. Secretary (Sending Branch)


Acceptance by the Receiving Branch

The ------------------------------------------------------ Branch (Name of receiving Branch) has accepted the membership and received the local branch contribution. Forwarded to Hony. State Secretary, with a request to intimate the transfer to Head Quarters.



Yours Sincerely

Hony. Secretary (Receiving Branch)

Copies of the application to be retained by each local branch





FOR IMA LIFE MEMBERSHIP APPLICATIONS - HEADQUARTERS COPY,LIMA COPY,STATE COPY AND BRANCH COPY --- - YOU CAN DOWNLOAD FROM IMA AP STATE WEBSITE OF HEADQUARTER'S WEB SITE.

INDIAN MEDICAL ASSOCIATION
I.M.A. HOUSE INDRAPRASTHA MARG, NEW DELHI-110002
MEMBERSHIP APPLICATION FORM
Life/Ordinary/Direct (in Quardruplicate)
Membership No.

HEADQUARTERS COPY

Membership Proposed by Dr. _______________________________ of

________________________ Local Branch IMA .

To,
The Honorary General Secretary,
Indian Medical Association
I.M.A. House Indraprastha Marg,
New Delhi - 110 002

Dear Sir.
I hereby apply to be enrolled a member of the Indian Medical Association as:
1) Branch Member of ________________________________________________________ Local Branch under________________________________________State/Territorial Branch .

2) Direct Member of IMA HQs/State _______________________________________________________________


Please fiIl in (BLOCKLETTERS}:

SURNAME ____________FIRST NAME ___________________________________

FATHER'S/HUSBAND'S NAME_________________________________________

ADDRESS ______________________________________________________________

______________________________________________________________________

Pin Code No: _______________

Tele No.(Clinic) _______________ Residence ___________

Date of Birth ___________________

QUALIFICATION

COLLEGE

UNIVERSITY

Registration No _________________ Date of Registration ___________________

Name of the Council of Registration ________________________________________

Are you in Service Yes/No. STATUS: GP / Consultant / Hospital Practice

I hereby declare that the qualifications or atleast one qualification (of the qualifications mentioned in my application) is recognised by the Medical Council of India and on that basis I am eligible to be registered with Medical Council or a State Medical Council.
If at any time my this statement is found to be incorrect, my membership, if granted will be liable to be cancelled and the fee paid by me to all sections of IMA will be liable to be forfeited ay them.

I hereby given undertaking that I shall abide by the Rules and Regulations of IMA.

Date ___________________
Place ___________________
Signature of Applicant

Certified that I have verified that qualifications and registration of the applicant and his eligibility as per Rules for being enrolled as members of the Indian Medical Association
Forwarded to the Hony. General Secretary alongwith HFC,

Hony Secretary ___________ Local Branch

Forwarded to IMA HQS on _______________ alongwith HFC
Hony, State Secretary (Signature)


Received IMA HQS alongwith HFC on______

Membership confirmed on______________

Hony, Secretary GENERAL (Signature)

Forwarded to JIMA alongwith HFC

The form to be filled in quardruplicate. The Secretary of the local Branch shall retain the "Local Branch Copy" and send the remaining three copies to the State Terr. Branch alongwith HFC “State Branch Secretary" forward the remaining copies duly signed to.the Headquarters, IMA Headquarters will send to JIMA.