THE INDIAN ASSOCIATION OF PHYSIOTHERAPISTS
APPLICATION FORM
(To be filled in Block Letters only)
PASSPORT SIZE PHOTO
Please enroll me as Ordinary / Life / Associate Member of the I.A.P.
Name ( Mr / Ms. / Mrs) ………………………………………………………………………………………………….... ………..……….…………………………………………………………………. Sex: [M] / [F] Nationality: Permanent Address …………………………………….. Date of Birth: ………/………/…….. (DD/MM/YY)
EDUCATIONAL QUALIFICATIONS (Use separate page if necessary) (A) PRE -- PROFESSIONAL -
School / College
Name of Board / University
Year of Passing
% of Mark obtained
(B)
PROFESSIONAL
School / College
Name of Board / University
Year of Passing
% of Mark obtained
Whether applying Fresh / Re – applying Whether a member of any other Medical Association: (Please specify) Any other relevant Particulars: I agree by the Constitution and Bye – laws of the Association and uphold its Ethical principles. I am remitted Rs……………………. as registration fee and membership subscription by Cash / D.D./No………………………Dated……………………of Bank…………………………….
Date: …… /…… / ………… [DD/MM/YYYY]
Signature of the Applicant
INFORMATION
(SUBSCRIPTIONS)
1. REGISTRATION 2. ORDINARY MEMBER : Rs. 500/: Rs. 300/-
(Common for All Membership) per annum (April to March) Physiotherapist qualified from I.A.P. recognized Institution in India
3. LIFE MEMBER 4. IAP-EXAM FEES
: Rs. 2000 /- One time Subscription : Rs. 500/-
Physiotherapist qualified from IAP non recognised institution in India / Abroad, Subject to approval by Executive council, I.A.P. Total Membership Fee Life Membership: Rs3000/IAP EXAM CANDIDATE -Including Exam Fees Rs 1500/-
8. CREDENTIAL VERIFICATION CERFICATE : Rs. 3000/- First Time,
Rs.1000/- Subsequent. All Payment by draft in favour of ‘‘Indian Association of Physiotherapists’’, payable at ‘‘Indore’’ addressed To
Dr. Anand Mishra Flat # 202, Unique Park, 8 FF, Scheme No 54 Vijay Nagar INDORE 452010(M.P) India
ANY SUBSEQUENT CHANGE OF ADDRESS MUST BE REPORTED TO THE GENERAL SECRETARY / TREASURER IMMEDIATELY. 0731-6560756 E-Mail: enquires.iap@gmail.com
"Minimum Criteria for sending Application - A copy of Degree/Provisional Degree Certificate from the University and Course Completion Certificate from College & Internship Completion Certificate from the college and all three attested by a Gazetted Officer must accompany the application."
Please note to enroll for IAP examination you should apply for Associate Membership also.
[For Office use only]
Remarks of Examination Committee (Associate members only):- Admitted / Rejected. Certificates Checked by Treasurer / General Secretary Enrolled as member Money received by On date Remarks: ……………………………………………Reg.No…………………………………………… ……………………………………………………… ………………………………………Receipt No ………………………………………….. …………….…………………………………………………………………………………..
Signature of General Secretary / Treasurer I.A.P. [20……. 20…….] [Incomplete / Incorrect applications are liable to be rejected
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