Prefix Select Dr. Mr. Mrs. Miss. * This field is required. First Name * This field is required. Middle Name Last Name Type Of Membership LM Member Beneficiary Member Gender Male Female * This field is required. DOB (MM/dd/yyyy) * This field is required. Age * This field is required. Enter Only Numbers Qualification MD DNB DVD DDV Others Atleast One Qualification required IADVL Member LM NO * This field is required. State Branch of IADVL --SELECT-- Arunachal Pradesh Assam Bihar Chhattisgarh Goa Gujarat Haryana Himachal Pradesh Jammu and Kashmir Jharkhand Karnataka Kerala Chandigarh Madhya Pradesh Maharashtra Manipur Meghalaya Mizoram Nagaland Orissa Andaman and Nicobar Island Punjab Rajasthan Sikkim Tamil Nadu Telangana Tripura Uttar Pradesh/Uttarakhand West Bengal Delhi LakshDeep Pondicherry MCI IMR Andhra Pradesh * This field is required. Address * This field is required. City * This field is required. State --SELECT-- Arunachal Pradesh Assam Bihar Chhattisgarh Goa Gujarat Haryana Himachal Pradesh Jammu and Kashmir Jharkhand Karnataka Kerala Chandigarh Madhya Pradesh Maharashtra Manipur Meghalaya Mizoram Nagaland Orissa Andaman and Nicobar Island Punjab Rajasthan Sikkim Tamil Nadu Telangana Tripura Uttar Pradesh/Uttarakhand West Bengal Delhi LakshDeep Pondicherry MCI IMR Andhra Pradesh * This field is required. Pin Code * This field is required. Enter Only Numbers Tel No. - STD Code Tel No. - Residence Enter Only Numbers Tel No.- Clinic Enter Only Numbers Mobile * This field is required. Enter Only Numbers Email Enter Valid E-Mail Address * This field is required.

Details of Payment
1. Admission Fees ( as per age)	Rs.
2. Annual Membership Fees(Increment of Rs. 50/- every year)	Rs.
3. Advance Fraternity Contribution(AFC)	Rs.
4. Legal Fees (optional/as per type of practice)	Rs. Select Fees 1000 3000
5. Advance Payment (optional)	Rs. Number Only
Total Fees	Rs.3250.00

Full Name of the Nominee * This field is required.	If nominee is minor, DOB (MM/DD/YYYY) Date out Of Range
Name of Nominee/Guardian with name in case of minor	Relationship with applicant * This field is required.
Address of Nominee * This field is required.	Proposed By. Dr. Proposed By. Dr. LM No/ DVL Welfatetrust No

Signature Of Nominee Upload a valid file * This field is required. [JPG,JPEG,PNG Only]	Signature (applicant) Upload a valid file * This field is required. [JPG,JPEG,PNG Only]
Signature Of proposer Upload a valid file [JPG,JPEG,PNG Only]

Note: Payment Link will be sent by office to the registered email.

	Hereby declare that the above information is true and I have withheld no information whatever in the Application, and I agree to pay the amount demanded.
	Further agree to abide by the conditions laid down in the constitution approved by the General Body for this Trust.