Indian society of oral implantologists



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INDIAN SOCIETY OF ORAL IMPLANTOLOGISTS

(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

(Please cross the mailing address in the box provided; if not marked, the Office address will be treated as the mailing address)

 a. Office: -________________________________________________________________ ___________________________________________________________________________City _______________ Pin __________ State ________________ Country______________

STD code Tel. no. (_____)__________ Pager no. _____________ Cellular no.____________

Fax. no.(______)__________ E-mail: - ___________________________________________

 b. Residence: - _____________________________________________________________ ___________________________________________________________________________

City _____________ Pin ________ State ______________ Tel. no. (______)_____________

3. My date of birth is ____/____/19_____ 4. My nationality is _________________


5. My marital status is Single / Married / Separated / Divorced / Widow / Widower,

6. My qualifications are

(Degree) (Year) (College / University)

a._______________________________________________________________________

b._______________________________________________________________________

c._______________________________________________________________________


7. My Dental Council Registration no. is __________ from ___________________State

8. My field of practice is __________________________________________________

9. I have / have not undergone training course in Oral Implantology, the details of which are

a. Lecture / Demonstration / Hands-on________________________________________

b. Duration / Date / Venue / Teacher__________________________________________

c. System _______________________________________________________________

10. I use the following systems in my practice___________________________________

11. I am a Fellow / Diplomate of International Congress of Oral Implantologists, USA.

12. I am a member of ______________________________________________________

(Professional bodies)


13. Membership Fees : -

Ordinary member: - Enrolment Rs. 100/- + Annual fees Rs. 800/- = Rs. 900/-

Life member: - Enrolment Rs. 100/- + Life fee Rs. 4000/- = Rs. 4,100/-



Overseas member: - Enrolment USD 10/- + Life fee USD 200/- = USD 210/-

(Life member only)

Student member Enrolment Rs. 50/- + Annual fees Rs. 250/- = Rs. 300/-

(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.


14. Dated ___________ Applicant’s signature _________________________________

___________________________________________________________________________



Please submit the completed application form along with the requisite fee (preferably by demand draft) & photocopy of Implant Course Certificate to: -

Secretariat: Dr. V.S.Mohan, Block No.9, Varma Nagar, Azad Road, Andheri East, Mumbai 400069

Ph: 022-26838188 / Cell No.9820142273

Email: isoi0050@gmail.com / drvsmohan2002@yahoo.com / drvsmohan@gmail.com

Website: www.isoimplant.com



( For office use only )

Application approved / rejected at Executive Council Meeting held on __ / __ / 2007.

Receipt no. _____ issued on __________2007.

_____________________ _____________________

(Hon. Secretary) (Hon. Treasurer)



Membership Requirements

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.


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