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.