This form may be used for NEW members or by existing members as an UPDATE
This form is for use by physicians and dentists only. Please complete all fields
Please mail the completed form along with payment to
Attention: Dr. Subhash Rege, MDS
406 Lanternback Island Drive
Satellite Beach, FL 32937
Brevard Indo-American Medical & Dental Association (BIMDA)
BIMDA is a not-for-profit professional association of physicians and dentists, IRS code sec 501 (c) (6).
BIMDA is a member affiliate of AAPI - American Association of Physicians of Indian Origin.
Membership in BIMDA is open to all physicians & dentists in good professional standing.
Membership application is subject to review and acceptance. All rights reserved by BIMDA.
BIMDA Federal Tax ID # 59-3576907
(Version: October 2017)