ICRI Membership Subscription

Member Name

Qualifications

Birth Date

Sex

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Address

State

City

Pincode

Phone: Clinic/Hosp.

Mobile No

Email ID

IRIA Membership Number

IRIA Member: since

IRIA Membership Document

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Name of Medical Council of Registration

Medical Council Registration No

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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

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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

PROPOSED BY MEMBER/ FELLOW OF ICRI

Name

Mobile No

Email ID

Address

IRIA Life Membership Folio No

Attach Proof

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Attach two recent passport size photographs.

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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

Name

Mobile No

Email ID

Address

IRIA Life Membership Folio No

Attach Proof

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Attach two recent passport size photographs.

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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)