IRA

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