IMSA

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Name
Address
Email
Phone
Mobile
Permanent Address
Email
Phone
Date Of Birth	(ex. 1999)
Sex
Birth Place
Nationality
Religion

Qualification	MCI Registration No.	Date of Regd.	Council

Course	University / Board / Institute	Location	Year Of Passing

Appointments / Assignments held, if any, with date:

List of Publications:

Membership of Professional Societies:

Any Other Achievements / Remarks:

Referers ( Names of two IMSA Fellows):

Referers 1.

Referers 2.

                              DECLARATION / UNDERTAKING BY THE APPLICANT

1. I declare that i have read the contents of the prospectus fully. Having understood the 
    information provided, Iam seeking Fellowship / Membership into IMSA on my own interest 
    and accord.

2. I declare that information furnished in this application is correct i.e., to the best of my 
    knowledge. I understood and agree that in the event of any information found to be 
    incorrect or false, I may be refused addmission to or debarred from the Academy.

3. If admitted into DIHMS I agree to abide by the rules, laws and regulation of the Academy 
    as amended from time to time.

4. I understand that Fellowship / Membership Fees once paid to IMSA will not be refunded 
    under any circumstance.

5. I will undertake the Fellowship Pledge to exemolify and develop the highest traditions of 
    the Noble profession of Medicine all over the world.

IMSA Fellowship / Membership Pledge

Recognizing that the International Medical Sciences Academy (IMSA) seeks to exemplify and develop the highest traditions of the Noble profession of Medicine all over the world :

I hereby voluntarily and unconditionally subscribe whole heartedly to the aims and objects of the Academy and to serve mankind through the Academy.
I hereby pledge myself as a condition of Fellowship in the IMSA to abide by its Constitution, and its Rules and Regulations and bye-laws, etc.
Further I pledge myself to work vigorously with enthusiasm in my field of specialty with honesty, dedication and scientific outlook and to advance constantly in knowledge, and to render willing help to my brothers/sisters in the profession.

Last but not the least, I pledge myself to cooperate in advancing and extending the ideals and principles of the IMSA and to work for the Health for All.

I confirm the above detail.