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Name  
Date of Birth  
Sex   Male
Female
Nationality  
Qualification/Titles  
Membership/Fellowship of other assoc./Soc.  
Achievments/Awards  
Modalities/Spl.interest  
Professional Address:-    
Street  
City  
State  
Country  
Zip  
Residential Address:-    
Mailing Address  
City  
State  
Country  
Zip  
Phone (office)  
Phone (Home)  
Fax (office)  
Fax (Home)  
Email  
Website  
Payment Detail    
Currency   U.S.Dollar
Indian Rupees
Bank Name  
Payment Mode   Credit Card
Wire Transfer
Bankers Cheque
Money Order
Number  
Date  
Amount  
Membership Fees   US$250.00
Fellowship Fees   US$350.00
                 

Note: Payment should be made in the name of "Indian Board of Alternative Medicines"
80, Chowringhee Road, Calcutta-700020 India










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