ICRI Membership Subscription

Member Name

Qualifications

Birth Date

Sex

Upload Photo

Choose file Note:Upload jpeg,jpg,png only and file size must be less than 5mb

Address

State

City

Pincode

Phone: Clinic/Hosp.

Mobile No

Email ID

IRIA Membership Number Note: Only Life Members/ Emeritus Membership are Eligible

IRIA Member: since

IRIA Membership Document

Choose file Note:Upload pdf only and file size must be less than 5mb

Name of Medical Council of Registration

Medical Council Registration No

Please Fill Out the Details

Name Instit/Hosp./Clinic

Designation

Teaching/Private Practice(Teaching)

Years

Teaching/Private Practice(Non-Teaching)

Years

Address

Country

State

City

Pincode

Telephone

Mobile No

Email ID

Biodata

Note:Upload pdf file only and file size should be less than 5mb Choose file

Please list the last 3 conferences/CMEs attended

Year

Place

Name of Conference/CME

Declaration

I, am a Life Member of IRIA for 3 years or more. I wish to enrol as a LIFE MEMBER of Indian College of Radiology & Imaging and as a confirmed Life Member, agree to abide by the currently existing constitution, rules and bye-laws of the College or which may be hereafter altered or amended from time to time

Date

There will an email sent to the proposer and seconder. Once they approve, your application will be processed from IRIA office. You are requested to inform the proposer and seconder to approve your application.

PROPOSED BY MEMBER/ FELLOW OF ICRI

Note: Enter IRIA Life Membership Folio No It will display remaining details.

Name

Mobile No

Email ID

Address

IRIA Life Membership Folio No

Attach Proof

Choose file

Attach two recent passport size photographs.

Note:Upload pdf only and file size must be less than 5mb

Attach Proof (scanned copy of any of the following IDs: PAN Card, Driving Licence, Voter ID Card, Aadhar, Passport, ID Card issued by IRIA HQ)

SECONDED BY MEMBER/ FELLOW OF ICRI

Note: Enter IRIA Life Membership Folio No It will display remaining details.

Name

Mobile No

Email ID

Address

IRIA Life Membership Folio No

Attach Proof

Choose file

Attach two recent passport size photographs.

Note:Upload pdf only and file size must be less than 5mb

Attach Proof (scanned copy of any of the following IDs: PAN Card, Driving Licence, Voter ID Card, Aadhar, Passport, ID Card issued by IRIA HQ)