Membership Registration Form - IPS Kerala: Indian Prosthodontic Society Kerala State Branch

Online Registration Form

* required fields

* Name:

* IPS National Membership Number:

* Date of Birth: (mm/dd/yyyy)

* Age:

* Gender:

* Present Position:

* Membership Applied for:

* Address for Communication (With PIN Code):

* Permanent Address (With PIN Code):

* Phone:

* Email:

Qualification

BDS
* College:
* Year of Passing:
* University:

MDS
* College:
* Year of Passing: (not applicable for students)
* University:

* State Dental Council Registered in with register number:

* Payment Details:

Message:

* Scanned image of
MDS Certificate (For Ordinary Life Membership) / BDS Certificate with a declaration attested by Head of Department (For Student Membership):

(Format: jpg, jpeg, bmp | Max 1MB file size)

* Scanned image of State Dental Council Registration Certificate:

(Format: jpg, jpeg, bmp | Max 1MB file size)

* Soft copy of Recent Colour Photograph:

(Format: jpg, jpeg, bmp | Max 200KB file size)

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INDIAN PROSTHODONTIC SOCIETY

KERALA STATE BRANCH

Online Membership Registration

Online Registration Form