International Dental Educationists' Association

International Dental Educationists' Association

[email protected]

Membership Application Form

Please fill all required fields

Title *

Name *

Date of Birth * (DD-MM-YYYY)

Gender *
Male Female

Nationality *

1) Communication Address

House No *

Apartment *

Street *

Locality *

City *

Country *

Zip Code *

Phone *

Email *

Permanent address same as Communication

2) Permanent Address

House No *

Apartment *

Street *

Locality *

City *

Country *

Zip Code *

Phone *

Email *

Academic Qualification *

Graduation, Post–Graduation, PhD, Post–doc fellow, Other

Sl	Degree	College / Faculty	University	Year
1
2
3
4
5

Details of Posts Held

Sl	College / Faculty	University	From	To
1
2
3
4
5

Details of Membership held in other professional associations

Sl	Name of the Association	Membership Type
1
2
3
4
5

Types of Membership Desired *

Life member Member

Membership Fee:
Life member – Rs. 5,000/-
Members – Rs. 1,000/- with annual renewal subscription of Rs. 750/- per year.

I confirm the information provided is correct.