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 : -

MEMBERSHIP TYPE AND FEES DETAILS (Membership Fee is revised from 1st April 2015)

 

Type of membership

Enrollment Fee

Membership Fee

Total

1

Life Membership (Active & Associate)

Rs. 500

Rs. 6000

6500 *

2

Overseas Membership

Dollars 50

Dollars 300

Dollars 350

3

Annual Membership (from April to March valid for one year only. Fees are payable for the full year irrespective of the month of joining)

Rs. 500

Rs. 2000

Rs.2500 *

4

Student Membership (from July to June valid for one year only. Fees are payable for the full year irrespective of the month of joining)

Rs. 500

Rs. 1000

Rs.1500 *




* Please add Rs.200 for Outstation Cheques











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 or cheque in the ISOI account at any branch of the Bank of Maharashtra or you can send online payment as per the following Bank details. Please send us zerox copy of the deposit receipt or payment details via email or with membership application form.

Please draw cheque in favour of ”Indian Society of Oral Implantologists”. Following is the bank details.


  • Name of the Beneficiary : INDIAN SOCIETY OF ORAL IMPLANTOLOGISTS

  • Name of the Bank & Branch : Bank of Maharashtra, T.H.Kataria Marg,

Himgiri Apartment, Mahim, Mumbai 400016

  • NEFT IFSC Code. : MAHB 0000093

  • Account Type : Saving Account

  • Account No. : 20002169228

  • RTGS IFSC Code : MAHB 0000093

  • Swift Code : MABHINBB

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. Uday Shetty, Shop #2 & 3, Anil Apartment, MTNL Road,

Prabhadevi,Dadar West, Mumbai - 400028

Phone Nos. : 022 - 24318181, 022 - 24304440, Cell No. 9820858181

Email: isoi0050@gmail.com /drudayshetty@yahoo.com



Website: www.isoimplant.com

( For office use only )

Application approved / rejected at Executive Council Meeting held on _______________

Receipt no. ______________ issued on _______________

_____________________ _____________________

(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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