Membership - IMPA

Role of IMPA

Due to the movement run by the great forefathers intellectual class developed. For running any movement money, time,
toil, skill, and mind (intelligence) is required. All these means necessary for the movement are available with the medical
professional and it is created because of the movement that was run by the great forefathers. In order to take this
movement towards its logical end IMPA has set before it this herculean objective.

Membership Form

Name

Date of Birth

Photo

Blood Group

Father / Husband Name

Permanent Address

Correspondence Address

Qualification

Hospital/ Clinic Name

Hospital / Clinic Address

Designation

Registration No.

Mobile No.

I declare that particulars given above are correct to the best of my knowledge & belief. If found incorrect, my membership would be cancelled and fee paid by me to IMPA will be liable to be forfeited by it. I hereby given undertaking that I shall abide by te rules/regulations of IMPA

Signature of Applicant

Date

Place

Cash/Cheque/DD Amount

Cheque/DD No.

Bank Name

Role of IMPA

Membership Form

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