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FORM OF APPLICATION FOR PROVISIONAL REGISTRATION UNDER SECTION 19

FORM – 11
(See rule 77)

FORM OF APPLICATION FOR PROVISIONAL REGISTRATION
UNDER SECTION 19

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 you to give the provisional registration under section 25 of the Indian Medical Council Act, 1956,and issue the necessary certificate. My praticulars are stated below :-

Name in full _______________________________________________

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

Address: ______________________________________________________________________

______________________________________________________________________

Maiden Name and Surname in the case of a married woman
(Begining with surname in block letters) __________________________________________________

Nationality :- _______________

Date of birth :- _____________

Qualification or examination passed :- ________________

Name of University or Licensing Body :-______________________________________________________________________________

Institution from which appeared for the
examination and number at the examination :-
___________________________________________________________________________________

Date of passing the examination or of
obtaning the qualification :-
____________________________________________________________________________________

2. I forward herewith :

(i) + My Birth Certificate

Matriculation Certificate

S . S . C . Examination Certificate.

School leaving certificate in original.

(ii) + the Degree

Diploma

Certificate of passing the qualifying Examination which I possess, in original.

These may be returned to me when no longer required.

3. I have been selected for :

*Practical training at the _____________________________________________________

( State name of approved institution )

*employment in a medical capacity at the____________________________________

_________________________________________________( State name of approved institution )

appointment in the Madical Service of the Armed force of the Union; and I enclose as evidence ______________________________

4. The registration fee including incidental charges is Rs.250/- when may be remitted

By Cash OR
By Money Order OR

5. I am applying for registration for the first time and I was not registered as a madical practitioner in India before the date of this application.

6. I have carefully read the instructions with this form and I cartify that praticulars above are true to the best of my knowledge and belife.

Date :
Place:

Your faithfully,

__________________
(Usual Signature )

1. All praticulars shall be filled by the applicant only .

2. All particulars should 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 applicants should rember that their names entered in the applicaton must exctly corrspond with their names at the University or other Examination, as the case may be .

5. Certificate form the Dean of the college regarding duration of Internship.

6. Attested copies of all the Original Certificates should be enclosed along with their Originals, otherwise Original Certificates will be retained in the Office of the Council.

7. You are requested to remit Rs. 50/- (Extra) if you desire to get your Provisional Registration Certificate by Registered Post.

8. In case of remittance by Crossed postal, Rs. 10/- extra will have to be sent to meet bank charges for realisation of the amount of the Indian Postal Order.

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

Strik off the alternative not applicable.

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