ONLINE MEMBERSHIP/FELLOWSHIP FORM
INTERNATIONAL ALTERNATIVE MEDICAL ASSOCIATION

Name:

Date of Birth:

Sex:

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Female

Nationality:

Qualification/Titles:

Membership/Fellowship of other Assoc./Soc.:

Achievements/Awards:

Modalities Practices, Specialities & Special Interests:

Professional Address-Street:

City:

State:

Country:

Zip:

 

Residential Address:-Street:

City:

State:

Country:

Zip:

Tele.(Home):

Tel.Office:

Fax-Home:

Fax-Office:

E-mail:

 

Website,if any:

Payment Details:-Bank Name:

Payment Mode:

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Currency:

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Amount:

Dated:

Note:Payment should be made in the name of "Indian Institute of Alternative Medicines"
80, Chowringhee Road, Calcutta-700 020 India
Membership Fees:US$100.00 Fellowship Fees:US$200.00

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