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Account Details

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Member Name *

Dr.

Father's Name *

Email *

DOB *

Age in Year & Month

Code *.

Mobile No. *

Code

Alternative Mobile No.

Sex *

Qualification *

Correspondence Address *

City *

State *

PIN *

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Nominee Details

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Name of the Nominee *

Relationship with Member *

Address of the Nominee *

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Nominee is minor

Yes

Name of the person who
represents the minor

His/Her Adress

Minor Date of Birth

Payment

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IRIA Folio No. *

Clinic

Suffering from any major illness

I, the undersigned here by apply for the membership of social security Scheme of Indian Radiological & Imaging Association.
I enclose here with Demand Draft/ at per towards scheduled free of my membership.

Applicant's Signature *

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Proposed By

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Proposed By *

Dr.

IRIA Folio No. *

Mobile No. *

Address *

State *

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Signature of Proposer *

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RULE OF ELIGIBILITY TO BECOME MEMBER OF IRIA - SSS

Any Life Member of IRIA upto age of 60 years residing in India is eligible to become a member of this Scheme.

RULE FOR BENEFIT:

The Scheme is purely designed on brotherhood/sisterhood basis & we try to help the family members of IRIA on event of death of member. Death Benefit of the Scheme is liable only after completion of one year of membership of IRIA-SSS. However, nominee of member be entitled for such benefits if death of member occurs in accident even within one year of joining the scheme.

NB

1. Life Membership of IRIA is compulsory.

2. Form must accompany Certified xerox copy of (1) Birth Certificate, (2) P.G. Degree/Diploma Certificate, and (3) Two passport size photographs.

I do hereby declare that, I am in sound state of my health and free any condition likely to cause my death in a short span of couple years. Above information including nomination details are true and given in sound state of my mind.I have with held no information what so ever regarding the application and I agree to pay the amount as per schedule of fees of the Scheme

I agree to pay the amount demanded from office of the scheme from time to time, as per constitution of the scheme and I further agree to abide by the rules and regulations laid down in the constitution of Social Security Scheme of IRIA & amendments made in it from time to time

Non payment of demanded amount after speculated date will lead to termination of membership as per bye laws of scheme.