Registration Form – Indian Association for Geriatric Mental Health

Salutation

Full Name

Qualifications

Proof of academic qualification(upto 10 MB file)

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Year of Passing MD/DPM/DNB/DM or Other Academic Qualifications

Age

Gender

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Other

Email Address

Mobile Number

Are you an Indian citizen or an Overseas Citizen of India (OCI)?

Indian CitizenOCI

If you are an Indian citizen – please upload Aadhar card If you are an Overseas Citizen of India – Please upload Aadhar/OCI card

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Complete Mailing Address

Professional Discipline

Please indicate your function in your job: (You may choose more than one):

Membership Category

Membership Proposed by

Membership Seconded by

For applicants residing in India: Life Time Membership Fee = Rs. 3,540/-
One-time Corporate Membership Fee = Rs. 11,800/-#
One-time Overseas Membership Fee = Rs. 11,800/-#
For applicants residing Overseas = US$ 750/- [# included 18% GST as per Govt. rules]

Method of Payment: Cheque/ Draft/NEFT/UPI

*Cheque/draft should be drawn in favour of "Indian Association for Geriatric Mental Health" payable at Agra. Overseas members are requested to pay only by demand draft. (Pl. add Rs. 60 as bank charges for out station cheques).

Bank Details: Bank and Branch: Canara Bank, Lohamandi, Agra A/c Name: Indian Association for Geriatric Mental Health Account No.: 0378101092206 (Saving Account ) IFSC Code: CNRB0000378 GST No. 09AAAAI1335F1Z2 (7th letter is capital i)

For UPI payments scan the QR code below

Payment details(With details like transcation no, date, Name of depositor etc.)

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Signature of the applicant

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