INDIAN SOCIETY OF ORAL IMPLANTOLOGISTS
(Society Register No. 1214 Public Trust Reg. No. F/21368, Mumbai)
Application for Fellowship in Oral Implantology
Affix Stamp
Size Recent
Colour Photo
2.5cm x 3cm
(Please type or write neatly in capital letters)
For Office use only
Admitted on ___/___/______
Awarded on ___/___/_______
1. I, Dr._____________________________________________________________________
(As you wish your name to be printed on your Fellowship Certificate)
Membership no. Ac/As /L/O/ H /_____ / _____, wish to apply for Fellowship of ISOI
2. Mailing address: ___________________________________________________________________________
___________________________________________________________________________
City _______________ Pin __________ State ________________ Country______________
Tel. no. (____)____________ , (____)__________________
Fax. no. (____)_________________ Cellular no.____________________________________
E-mail: - ___________________________________________
3. Date of birth ___/______/ 19_____
4. Nationality ______________________
5. Qualifications
(Degree)
(Year)
(College / University)
a. _________________________________________________________________________
b. _________________________________________________________________________
c. _________________________________________________________________________
6. I have completed at least 10 Implant Cases the details of which are described on the
accompanying pages in a binder / loose leaf book format / CD.
7. Enclosed Rs. / USD ___________ by Bankers cheque / by Demand draft no.___________,
dated ______, drawn on _______________________________________ Branch in favour of
“ISOI Accreditation fund” payable in Mumbai.
8. Applicant’s signature _________________________________ Dated ____/_____/ 2006.
Please submit the completed application form along with the requisite fee (preferably by demand draft)
& the Case materials to :
Secretariat: Dr. V.S.Mohan, Block No.9, Varma Nagar, Azad Road, Andheri East, Mumbai 400069
Ph: 022-26838188 / Cell No.9820142273
Email: isoi0050@gmail.com / drvsmohan2002@yahoo.com / drvsmohan@gmail.com
Website: www.isoimplant.com
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Requirements for Fellowship: (a) Members of atleast one year standing are eligible to apply for Fellowship
(b) Application fee -Indian Member Rs. 5,000/-; Foreign Member US $ 300/-. For outstation
cheque, add Rs. 50/-.
This fee includes a non-refundable processing fee of 10% of the above amount. If application
is rejected 90% of the application fee will be refunded.
(c) Fellowship may be earned through fulfilment of 10 implant cases with 1 year of clinical
and radiographic follow-up
(d) Case presentation shall include
(i) OPG – Pre and 1 year Post-operative, and Intra-oral peri-apical Radiographs,
(ii) Study Models,
(iii) Photographs or Slides,
(iv) Case History and Summary of the patient,
(v) Case records shall be returned on completion of review.
( For office use only )
Application approved / rejected at Accreditation Committee Meeting held on __ / __ / 200_.
Receipt no. ___________ for Rs.5,000/- / US$ 300/- issued on ________________.
Fellowship awarded on ____________________
_____________________
_______________________
(Chairman, Accreditation Committee, ISOI)
(President, ISOI)
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