Indian Rheumatology Association
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Re-registration Enquiry
IRA Membership Re-registration Enquiry Form
Personal Information
Full Name
Date of Birth
Email Address
Phone Number (Current)
Phone Number (Previous, if known)
Address Information
Current Address
Street
City
State
Postal Code
Previous Address (if known)
Street
City
State
Postal Code
Professional Information
Name of Practice/Hospital
Address
City
State
IRA Membership Information
IRA Membership Number (if known)
Approximate Date of Joining
Verification Information
Preferred Method of Contact for Verification
Phone
Email
Additional Comments
Comments
I hereby declare that the information provided above is true and accurate to the best of my knowledge. I understand that this information will be used for the purpose of re-registering my IRA membership.
For any assistance/query related to re-registration please email us at
admin@indianrheumatology.org
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