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:
    Borad Certification year:
    Documentary evidence of MD certificate/ board certification certificate:




    Membership
    Select Membership type

    Life Membership
    Life Membership Criteria: MD in Medicine awarded by PGIM, University of Colombo, Sri Lanka AND having full board certification as a Specialist in Internal / General Medicine.
    Associate Membership
    Associate Membership Criteria: MD in Medicine awarded by PGIM, University of Colombo, Sri Lanka AND practicing as a Senior Registrar / Acting Consultant in Internal/General Medicine.
    Life membership fee - Rs 5000/=
    Associate Membership fee - Rs 3000/=

    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.