Indian Medical Association of Greater Los Angeles
912 Teakwood Road Los Angeles CA 90049
310 786 7100
Fax 310 4724459
APPLICATION FORM
Name:__________________________________________________________________________________________________________________________
Home Address:___________________________________________________________________________________________________________________
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Office Address:___________________________________________________________________________________________________________________
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Telephone Numbers:
Home:______________________________________________________________Office:______________________________________________________
Fax:____________________________________________________Email:___________________________________________________________________
Medical School:_____________________________________________________Year of Graduation:____________________________________________
Speciality:_______________________________________________________________________________________________________________________
Spouse Name:___________________________________________________________________________________________________________________
Children:_______________________________________________________________________________________________________________________
Hobbies/Interests:________________________________________________________________________________________________________________
Medical Topics of Interest:_________________________________________________________________________________________________________
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Life Member:__________________________________________________________________________Annual Member:___________________________
Annual Dues: $ 100.00
Life Membership: $ 750.00
Residents & Interns: $ 50.00
Please print this form, fill it out and mail with a check payable to I.M.A. of Greater Los Angeles to
Gopal Batra, M. D. 912 Teakwood Road
Los Angeles CA 90049
NOTE: We will appreciate your urgent attention to this form. Kindly complete and mail along with your dues to keep your current information updated.
DUES ARE FOR JULY TO JUNE
A Non-profit Organization, TIN 95-4393229