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Permanent Address
Date Of Birth  (ex. 1999) 
Birth Place  

Qualification MCI Registration No. Date of Regd. Council

Course University / Board / Institute Location Year Of Passing

Appointments / Assignments held, if any, with date:
List of Publications:
Membership of Professional Societies:
Any Other Achievements / Remarks:
Referers ( Names of two IMSA Fellows):
Referers 1.
Referers 2.
IMSA  Fellowship / Membership Pledge

Recognizing that the International Medical Sciences Academy (IMSA) seeks to exemplify and develop the highest traditions of the Noble profession of Medicine all over the world :

  1. I hereby voluntarily and unconditionally subscribe whole heartedly to the aims and objectives of the Academy and to serve mankind through the Academy.
  2. I hereby pledge myself as a condition of Fellowship in the IMSA to abide by its Constitution, and its Rules and Regulations and bye-laws, etc.
  3. Further I pledge myself to work vigorously with enthusiasm in my field of specialty with honesty, dedication and scientific outlook and to advance constantly in knowledge, and to render willing help to my brothers/sisters in the profession.
Last but not the least, I pledge myself to cooperate in advancing and extending the ideals and principles of the IMSA and to work for the Health for All.
I confirm the above detail.
IMSA International Medical Scieces Academy
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