FORM 19 ( See rule 92 ) APPLICATION FOR RE-ENTERING NAME IN THE REGISTER
To, The Registrar, Gujarat Medical Council,
(1) I, the undersigned (i) ____________________________
(i) Insert full name.
__________________ now holding the qualification (ii) ___________________ apply for re-entey of my name in the Register.
(2) By the order dated (iii) __________ the Gujarat Medical Council, made by name to br removed from the Register on a complaint made by (iv) _____________________________ _______________ and the miscondust for which the Council directed the removal of my name was (v) ______________
(3) Since the removal of my name from the Register, I have been residing at (vi) __________________________ and my occupation has been (vi) ________________________
(4) It is my intention if my name is re-entered in the Register to (vii) _________________
(5) The grounds of application are (viii)
(6) I forward herewith :-
(a) the degree / diploma / licence of ________________ in original.
(ii) Insert qualifications, if any. (iii) Insert date. (iv) Insert name and address of complainant, if any, (v) Insert charge on which name was removed. (vi) These blanks must be filled in according to circumstances . (vii) Insert particulars as to proposed future professional occupation. (viii) All facts and grounds on which the appllication is made should be clearly and concisely stated. (ix) Insert name of Gazetted Officer or J.P. giving the certificate.
