Welcome to IAE Karnataka

1. Name*:

2. Age *:

Gender :

Male

Female

3. Address

a. Primary/Permanent Address * :

City / Town *:

PIN Code *:

State *:

Telephone :

b. Secondary Address (Clinic / Hospital / Institute / Temporary) :

City / Town :

PIN Code :

State :

Telephone :

c. Mailing Address : (Please select preferred mailing address)

Primary

Secondary

d. Email *:

Mobile * :

4. Profession :

Doctor (Allopathy) Sonographer (Certified / Non Certified) Others

5. Degree/Certificates/Fellowships :

6. Area of Echo Interest :

7. Experience in Echo : *

Doing Echo

RegularlyOccasionally

Since :

Interested in Echo, no Experience

Others (Specify)

8. Medical Registration Number (KMC or Others) :

9. National IAE Membership Number :

10. Membership of other professional societies :

11. Permanent Membership Fee :

Doctor (Allopathy) : Rs 1500/-Sonographer : Rs 500/-Others : Rs 1000/-

New Member Application