Basic Infromation Applicant’s Full name: Surname with initials: Address (Residence): Hospital/Faculty: Telephone:* Email: Date of Birth: Civil Status: Gender: FM 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: Name Email Work station Mobile number Name Email Work station Mobile number 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. Yes