Indian Dental Association

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Membership Details

Date :

Type :

Field is required.

Mem Type :

Membership Fees :

Field is required.

Check Email Id :

General Info

*Title :

*First Name:

Middle Name:

*Last Name:

Pref Name:

DOB:

Gender:

Blood Group:

Qualification Details

Under Graduation

*Qualification:

*University:

College:

*Pass Date:

Post Graduation

Qualification:

Specialization:

University:

College:

Dental Practice :

Dental Practice Sub :

Pass Date:

Mailing Address

*Address 1:

Address 2:

Address 3

*Country:

*State:

City:

Taluka:

Village:

*Area:

*Pin:

Tel1:

Tel2:

Fax:

Contact Info

Mobile:

Mobile is too short.

Mobile is too long.

Alternate Mobile:

Email:

Alternate Email:

State Dental Council Registration

SDC:

Reg No:

State Branch :

Local Branch :

{{objpaymentdata.txtrdopaymode}} No:

{{objpaymentdata.txtrdopaymode}} Date :

Bank Name :

Reference No:

Source:

Coordinating Person:

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Order No	Amount	IDA Membership type	Action
{{db.orderno}}	{{db.amount}}	{{db.memtype}}

{{data.name}} IDAHO {{data.IDAHONew+data.IDAHOReNew}} State {{data.StateNew+data.StateReNew}} Local {{data.LocalNew+data.LocalReNew}} Student Wing {{data.Student_wingNew+data.Student_wingReNew}} NSSS {{data.NSSS}} {{data.RegFee}} {{data.name}} IDAHO {{data.IDAHOReNew}} State {{data.StateReNew}} Local {{data.LocalReNew}} Student Wing {{data.Student_wingReNew}} NSSS {{data.NSSS}} {{data.RenewalFee}}