Basic Infromation

    Applicant’s Full name:

    Surname with initials:

    Address (Residence):

    Hospital/Faculty:

    Telephone:*



    Email:

    Date of Birth:

    Civil Status:

    Gender:

    Qualification

    MBBS qualified year:

    SLMC Registration Number:

    MD qualified year:

    Board Certification year:

    What are your special interests:

    Additional professional courses you have followed and completed:

    Documentary evidence of MD certificate/ board certification certificate:




    Membership

    Full membership fee - Rs 5000/=

    Account number – 1730032500 Commercial Bank, Peradeniya.
    Account name – SRI LANKA COLLEGE OF INTERNAL MEDICINE

    Upload payment receipt (image/pdf):

    Name 2 referees having collage membership:

    By clicking "yes", I certify that I hold a current active medical license and I shall not misuse my membership status In SLCIM regulations. I declare that particulars given above are accurate.