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FORM OF APPLICATIOB FOR REGISTERATION UNDER SUB-SECTION 93) OF SECTION 16.

FORM – 7
(See rule 73 )
FORM OF APPLICATION FOR REGISTRATION UNDER SUB – SECTION (3)
OF SECTION 16.

To
The Registrar,
Gujarat Medical Council,
Opp. Maniben Aruvedic Hospital,
Nr. FSL, Old Cariology Bldg.,
B/s. Civil Hospital Post Office,
Ahmedabad-380016

Sir ,

I request to register my name and other praticluars, as stated below under the Gujarat Medical Council Act,1967 and further to give certificate of registration:-

Name in full:- _______________________________________________________

(Beginning with surname and including father`s / hhusband`s name in block letters only )

Address:- ______________________________________________________________________
_______________________________________________________________________________

( To be entered in the register ).

Maiden name and surname in case of a married women :- ______________________

(Beginning with surname in Block-letters)

Nationality:_____________

Date of birth: ______________

_______________________________________________________________________________

Description of qualifications of which registration is desired. The name of the University or the Liecnsing Body should also be stated.

Date of obtaining the qualifications . State also the Institution from which you appeared for the said examination , alongwith your number
at the examination.

1. Date of Completion of internship __________

2. Institution _______________________

3. Roll No. at the Final MBBS Examination ______

4. Examination Center _______________

2. I forward herewith--

(i) My birth certificate
matriculation certificate OR
S.S.C. Certificate . OR
School leaving certificate

In original: And

(ii) * The Degree
Diploma
Licence
Certificates

Other evidence in support of my having obtained the qualification Which I possess,in original . The above documants my please be retuened to me when no longer required.

The registration fee of	Rs. 1000 /- (Rupees One Thousand only)
Postal charge	Rs. 0050 If desired by Registered Post/
Toal	Rs. 1050

By Cash/	By Money Order/	By Crossed Indian Postal Order
by Demand Draft in favour of Registar Gujarat Medical council.

________________________________________________________________________________

* 4. I am applying for registration for the first time and I was not registered as a medical practitioner under any law in India before this .

________________________________________________________________________________

* 4. I am/ was provisionally registered under section 25 of the Indian Medical Council Act, 1956 and enclose the certificate of provisional registration in original.

________________________________________________________________________________

*4. I was/have been registered under the _____________________________

(State the Act or Law)

in the year _______ And my registration number is-was _____________________

5. I have carefully read the instructions sent with this form and I certify that the praticulars funished above are true to the best of my knowledge and belife.

Yours faithfully.

( Usual Signature )

Date:

SPECIMEN OF PRACTITIONER`S SIGNATURE AS USED ON MEDICAL CERTIFICATE

Speciman Signature
____________________________________________________________________________________

PRESENT ADDRESS

INSTRUCTIONS

1. All particulars in the application shall be filled by the applicant only.

2. All praticulars be in neat legible hand.

3. The registration fee should be sent in person or by money order or crossed postal order. When the fee is sent by money order, the postal receipt should be attached to the application .

4. The applicant should remember that their names entered in the application must exactly correspond with their namess at the University or other Examination, as the case may be.

5. All the Original Certificates should be enclosed alongwith the Xerox copies, otherwise original certificate will be retained in the office of the councial.

6. In case of remittance by Crossed Postal Order Rs. 30/- (Thirty) extra will have to be sent to meet bank charges for realisation of the amount of Indian Postal Order.

7. Xerox Copy of Internship Completion certificate issured by the Dean/Priniciple of your college should also be forwareded.

8. Evidence regarding change of Name, Surname be sent viz. Gazette/Marriage Registration Certificate as the case may be.

9. Provisional Degree Certificate i.e. Internship Completion Certificate granded by university be forwarded in Original with copy, if the Degree Certificate has not been received from the university.

10. Attempt certificate granted by the Baroda University be forwarded in original with one xerox copy.

11. No objection certificate will be required to produce alongwith Registration certificate in case of Applicant is registered with any other state medical council.

________________________________________________________________________________

* Strike off the alternative not applicable

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