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*SELECT BRANCH *SELECT CATEGORY :
PERSONAL DETAILS
* NAME( As Per Degree ): *DATE OF BIRTH : * PLACE OF BIRTH : * GENDER : * NATIONALITY : * BLOOD GROUP : * FATHER NAME : MOTHER NAME : * EMAIL - ID : *MOBILE NO : AADHAAR CARD NO : * MARITAL STATUS :
MAILING ADDRESS

* ( Please indicate preference of mailing address )

 
PROFESSIONAL / CLINIC ADDRESS
*ADDRESS LINE 1 : *ADDRESS LINE 2 : *COUNTRY : *STATE : *DISTRICT : * MANDAL : * CITY : *PINCODE :
RESIDENTIAL ADDRESS
Same as Professional Address
*ADDRESS LINE 1 : *ADDRESS LINE 2 : *COUNTRY : * STATE : *DISTRICT : * MANDAL : *CITY:
   
*PINCODE :
   
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DECLARATION

* I, Dr.  Declare that i have read all the details of IDA Constitution , Bye-Laws , NSS Scheme - rules & regulations , Code Of Ethics & professional conduct and resolve to abide by them . I am Not a member of any association functioning parallel to APIDA ( this do not include in specially societies ) in my area have not been convicted by any court of law. i am not engaged in any activity detrimental to the interest of association. I solemnly declare that the contents of this application form are correct to the best of my knowledge and information. i agree that if anything contained herein found to be false , my membership of Andhra Pradesh Indian Dental Association is liable to the Cancelled Immediately.

GRADUATION (BACHELOR'S DEGREE)
* ACADEMIC FROM : *PASSING MONTH & YEAR : *QUALIFICATION :
 
*STATE : *UNIVERSITY : *INSTITUTE : *PLACE OF COLLEGE :
 
POST GRADUATION (MASTER'S DEGREE)
ACADEMIC FROM : PASSING MONTH & YEAR : QUALIFICATION :
STATE : UNIVERSITY : INSTITUTE : PLACE OF COLLEGE :
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ATTACHED DOCUMENTS
*TYPE OF DOCUMENT :

 
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