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  Visit the Ad Council's children's oral health website

Family Benefit Scheme Registartion for 2023

FBS Registration

DSBT - FBS MEMBERSHIP FORM

Personal Information

* SUR Name

* Name

* Gender (Required)

* Date of Birth Please Enter Date of Birth Invalid Date

* Your Age

* Registartion Fee

* Contributory Deposit

* Total Amount

IDA / SPECIALTY DENTAL ASSOCIATION MEMBERSHIP NO (Required)

* Number (Required)

* Do you have any health problems ? (Required)

* Mobile Invalid Mobile

* Email

* Mother / Father / Spouse (Required)

* Name

Attachments

Upload Passport Size Photograph

Upload Aadhar with signature

Upload State Dental Council registration certificate

Upload Association membership card

(Required) * Date of birth proof

Upload Date of birth proof

FBS Correspondence to be sent to this Address

* Address

* City

* District

* State

* PinCode Invalid Pincode

* Phone Invalid Phone

Permanent Address Same as FBS Correspondence Address

* Address

* City

* District

* State

* PinCode Invalid Pincode

* Phone Invalid Phone

Nominee 1

* Full Name

Relation

Mobile

Percentage of Benefit

Upload Adhar Card with signature/ thumb impression

Nominee 2

* Full Name

Relation

Mobile

Percentage of Benefit

Upload Adhar Card with signature/ thumb impression

Nominee 3

* Full Name

Relation

Mobile

Percentage of Benefit

Upload Adhar Card with signature/ thumb impression

Reference / Information of DSBT FBS provided by -

OTHER (MENTION REFERENCE)

I do hereby declare that the above information is true and I have not withheld any information whatsoever regarding my particulars and my membership can be terminated if any information is found to be incorrect. I agree to pay the Fraternity Contributions as per the rules and regulations of this Scheme.

I, further agree to abide by all the rules & bye-laws of DSBT - “Family Benefit Scheme” and also any amendments to be made from time to time in the constitution / by laws of FBS. I will not proceed legally against DSBT - Family Benefit Scheme, without going to the Arbitration Committee of the FBS. Any change of my address will be informed to FBS office from time to time.

Note: Please fill up the form and complete the payment. For any other clarification you can contact us at familybenefitscheme@gmail.com