(Society Register No. 1214 Public Trust Reg. No. F/21368, Mumbai)
Affix Stamp Size Recent Colour Photo 2.5cm x 3cm
For Office Use only
Ac / As ; L / O ; _____ / _____
Admitted on ___/____/_______
Application for Membership (Please type or write in capital letters)
1. I, Dr./ Mr./ Ms.___________________, _____________________________________
(Surname) (First name) (Middle name)
wish to apply for Active / Associate, Life / Ordinary membership of the ISOI,
Referred By __________________________________________________________
I would like to have my name to be printed on the Membership Certificate as : ______________________________________________________ 2. My address is
(Annual membership fees are for the financial year April 01 to March 31. For Students Annual membership fees are for academic year July 01 to June 30. These fees are payable for the full year irrespective of the month of joining)
Add Rs. 100/- for outstation cheque.
Enclosed Rs. / USD ___________ in cash / by cheque / by demand draft no. _____________,
dated _________, drawn on ____________________________________________________
______________________ Branch in favour of “Indian Society of Oral Implantologists” payable in Mumbai. You can deposit cash in the ISOI account No.20002169228 (Branch Code 0093 T.H.Kataria Marg, Mahim,Mumbai 400016 branch) at any branch of the Bank of Maharashtra. Please send us zerox copy of the deposit receipt with membership application form.
1) Active member: - The applicant should hold atleast a B. D. S. degree from any University in India recognised by the Dental Council of India and should produce documentary evidence that he / she has attended atleast one training course in Oral Implantology in any system and / or has some background in Implant practice.
2) Associate member: - Associate membership is open to Dental Laboratory technicians, Dental Hygienists, Dental / Implant manufacturers & dealers, Physicians, Surgeons & Research Personnel.