Indian Prosthodontic Society

Please download the Registration Form and forward properly filled registration form along with relevant documents to Hon. general secretary cum treasurer.

Please Fill the below online Registration Form and submit the scanned copy of relevant supporting documents

INDIAN PROSTHODONTIC SOCIETY
MEMBERSHIP FORM

To,
Dr.V.RANGARAJAN
Indian Prosthodontic Society
Hon. General Secretary cum Treasurer
230, Avvai Shanmugham Salai,
Royapettah, Chennai - 600014
Tamil Nadu, India

Dear Sir,

I wish to became an Ordinary life member/ Student member of the Indian Prosthodontic Society and agree to abide by the rules and regulation of the society.

I am herewith enclosing the requisite amount Rs. by Cash/Cheque/D.D. No dt.. as per details below together with my bio-data, copy of MDS degree (Prosthodontics) & DCI Registration Certificate duly attested by Gazetted Office and one passport size photograph on glossy paper.

Life Membership Fee	:	Rs. 4,000.00
Entrance Fee (New Members)	:	Rs. 500.00
TOTAL	:	Rs.4, 500.00

NOTE: -
1. Details to be filled in by the applicant in block letters only.
2. Cheque/DD to be drawn in favour of “INDIAN PROSTHODONTIC SOCIETY” payable at Chennai.
3. Please include Rs.50/- in case of Out-Station Cheque towards Bank Charges.
4. In Case of Ordinary life member, enclose copy of MDS degree (Prosthodontics) and Dental Council of India Registration Certificate duly attested by Gazetted Officer.
5. In case of Student members enclose copy of Dental Council Registration Certificate duly signed by Gazetted Officer and Bonafide Student Certificate attested by HOD Prosthodontics/ Principal.
6. Student Life membership will be converted to ordinary life member on submitting MDS Degree Certificate without additional payment.

Member Type

Choice of Mailing Address

RESIDENCE OFFICE

PASSWORD

CONFIRM PASSWORD

FIRST NAME

LAST NAME

PRESENT POSITION

DATE OF BIRTH

- mm/dd/yyyy format

DENTAL COUNCIL REGISTRATION NO

STATE OF

OFFICE ADDRESS

CITY

STATE

TEL NO

--
ISD-STD-Phone No.

FAX

--
ISD-STD-Fax No.

OFFICE EMAIL

RESIDENCE ADDRESS

CITY

STATE

TEL NO

--
ISD-STD-Phone No.

MOBILE

-
ISD-Mobile No.

PERSONAL EMAIL

WEB

EDUCATIONAL QUALIFICATION

DEGREE	INSTITUTE	UNIVERSITY	YEAR OF PASSING
B.D.S
M.D.S

Please attach your photo

(Image size should be 150*80 and not more than 20 kb)

Other Information :

Note : Once you filled the above form, online facility to submit your all relevant scanned Documents are
provided. Kindly use it to send your documents safe and faster.

Mail to:

Dr.V.Rangarajan
Indian Prosthodontic Society
Hon. General Secretary cum Treasurer
230, Avvai Shanmugham Salai,
Royapettah, Chennai - 600 014,
Tamil Nadu, India
Mobile :   9445098096
Phone   :   044-28133186
Fax        :   044-28131094
E-mail   :   info@ipsonline.in / secretary@ipsonline.in
                   president@ipsonline.in / editor@ipsonline.in
Web    :   www.ipsonline.in

Payment Method

You have to make DRAFT / CHEQUE in favour of "Indian Prosthodontic Society" payable at CHENNAI, INDIA and send to the below address.
or
Deposit cash in our ICICI Bank Account, favouring "Indian Prosthodontic Society" payable at CHENNAI. Account No.602201201589.

Indian Prosthodontic Society
Dr.V.Rangarajan
Hon. Gen. Secretary cum Treasurer,
230, Avvai Shanmugham Salai,
Royapettah, Chennai - 600 014,
Tamil Nadu, India