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Membership Application Form

Personal Details

Member ID :

Salutation :

Academic title(s) :

Full Name :

(*As appear in NIC or Travel document)

Name With Initials :

Preferred Name :

Nationality :

National Identity Card No (NIC):

Gender :

Date of Birth :

Place of Birth :

Contact Information

Email :
Re-type Email :

Postal Address :

Profession :

Place of work and Address :

Contact Phone Numbers :

Mobile Office

Residence Fax

Preferred contact number for Communication :

Profesional Qualifications

Medical Degree (with details) :

Medical School :

Post Graduate Qualifications (with dates) :

a). Diagnostic Radiology/ Radiotherapy & Oncology. b). Other Qualifications

Special Interest

Special Interest :