INDIAN PHARMACY GRADUATES' ASSOCIATION (Regd. Under Registration of Societies Act. XXI of 1860, Regn. No. S/8255 of 1976) Head Quarter : F-2, 1st Floor, A Block Shopping Complex, Meera Bagh, New Delhi-110087 Website : www.ipga.in  MEMBERSHIP FORM
NAME
Please click as applicable Dr. Prof. Mr. Ms. Mrs.
Last Name / Surname		First name
Middile Name		Image
PERMANENT ADDRESS
Area / Locality / Village
Town / City / District		Pin Code
Phone		Fax
Mobile		E-mail
OFFICIAL ADDRESS WITH DESIGNATION
Organisation
Address		Pincode
EDUCATION QUALIFICATIONS
Degree Year of Passing Name of Institute University B.Pharm.* M.Pharm. Ph.D.
Date of Birth		Blood Group
Marital Status(Married/Unmarried)	Select Marital Status Married Unmarried	Date of Marriage
Click on the appropriate box Type of Membership		Life Member    Associate Life Member	Ordinary Member    Institutional Member
PAYMENT DETAILS : Enclose Draft/Cheque* in favour of "IPGA New Delhi"
Amount (in words)
Cheque / Draft / Pay order No.		Dated
Drawn on (Bank Name)		Branch
Please select appropriate	Cash    Cheque    Draft / Pay Order	Rs
Add Rs.: 50/-for outstation cheaque.
UNDERTAKING
Certified that the information given in the form are true to the best of my Knowledge.I shall adide bby all the rules and regulations of the Indian Pharmacy Graduates' Association.
Date	March 10, 2010	Place
MEMBERSHIP FEES
Life Member	Rs.: 2000/- + Registration Fee Rs.: 100/-		Total Rs.: 2100/-
Associate Life Member (For Students only)	Rs.: 2000/- + Registration Fee Rs.: 100/-		Total Rs.: 2100/- (Associate Life Member will become Life Member after completion of B. Pharmacy)
Institutional Member	Rs.: 8000/-		Total Rs.: 8000/-