IMA JALNA MEMBER DETAILS UPDATION FORM
Form for Updation of Member Details IMA records and Website
First Name *
Enter your first name only. Do not prefix Dr.
Middle Name *
Enter your middle name i.e. Father's / Husband's name
Last Name *
Enter your last name i.e. Surname / Family name
Degrees *
Enter your degrees
Practice Type *
Enter your practice type / specialisation. eg. Radiology, Surgery etc.
Hospital Address *
Enter postal address of your Hospital / Clinic
Place *
Enter your place of practice. If small place, enter Taluka also.
Pin Code
Enter the pincode of your place of practice
Phone Number/s
Enter your landline number that should be displayed on the website. Enter STD code before the number
Mobile Number/s
Enter your mobile number for use of the Association. This will not be displayed on the website.
E-mail ID
Enter your E-mail ID. This will be displayed on the website.
Spouse Name
Enter your spouse's name. This will not be displayed on the website.
Type of Membership *
Choose your membership type from the drop-down list
MMC Registration No.
Enter your MMC Registration Number
IMA Life Membership No.
Enter your IMA Life Membership Number. Annual and Allied members leave blank.
IMA NSSS No.
Enter your IMA National Social Security Scheme Number. Annual and Allied members leave blank.
IMA MS SSS No.
Enter your IMA Maharashtra State Social Security Scheme Number. Annual and Allied members leave blank.
IMA NPPS No.
Enter your IMA National Professional Protection Scheme Number. Annual and Allied members leave blank.
IMA NHS No.
Enter your IMA National Health Scheme Number. Annual and Allied members leave blank.
Birth Date *
Enter your original date of birth. Official dates are not required.
MM
/
DD
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YYYY
Wedding Date
Enter your wedding date.
MM
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DD
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YYYY
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