New Member Registration

Please complete the registration form below and provide the required information and supporting documents.

Personal Information

Member Name *

Date of Birth *

Age

Gender *

PAN Number

Member Type *

Branch *

Other Branch

Document Uploads

Member Photo Allowed formats: JPG, JPEG, PNG.

PAN Card Document Allowed formats: JPG, JPEG, PNG, PDF.

Aadhaar Card Document Allowed formats: JPG, JPEG, PNG, PDF.

KMC Certificate Allowed formats: JPG, JPEG, PNG, PDF.

KMC & Membership Details

KMC Number

Admission Amount (Including 18% GST)

Contact Information

Email Address *

Mobile Number *

PIN Code

City

Permanent Address *

Correspondence Address

Nominee Details

Nominee Name

Nominee Relationship

Additional Information

Motivated By

Additional Phone Numbers / Emails

Declaration

I hereby declare that the information provided above is true and correct to the best of my knowledge. I agree to abide by the rules and regulations of the IMA Karnataka State Health Scheme.