APPLICATION FOR PROVISIONAL REGISTRATION

APPLICATION FOR PROVISIONAL REGISTRATION .................... Receipt No.. Date. ............................. (For office use) To, The Registrar, Nagaland Medical Council. Sub: provisional Registration. photogmph attested Sir, I hereby request that my name and other particulars mentioned below may be entered in the State Provisional Register of Nagaland Medical Council as required under section of the Nagaland Medical Council Act 2014. Name of the Application(block letters) Father's / Husband's Name Mother's Name Gender Date of Birth (date, month, year) Nationality Category (General /APST) Address a. Residential Address b. Permanent Address c. Professional Address Telephone No./Mobile No./Fax No./Email ID Details of Qualification a) General Decree: b) Medical Degree: S1. No 1 1. Name of the Institution where applicant has been Selected for practical training (whether the Hospital Or Institution) where such training is to be undertaken is recognized by the Medical Council of India Description of Qualification S1 No. 12. Name of the Medical College attended ........................................... I hereby submit a Bank Draft No Dated .................................. obtained from (Bank) .......................................... for Rs. 500/- (Rupees Five Hundred) as non refundable fee in favour of Nagaland Medical Council. Name of the Schoo l/ College Roll No/ Registration No. Name of the Board/ University Name of the Medical College / Institution Year of Qualification Name of the University/ Licensing Authority Year of passing DECLARATION I solemnly affirm and declare that the particulars furnished above by me are true to the best of my knowledge and belief and I undertake to abide by the code of conduct & Ethics of Nagaland Medical Council and by the Rules of Nagaland Medical Council. Date: Signature of the Applicant Note: 1. Application to be submitted at the office of the Nagaland Medical Council along with three recent passport size photographs. 2. Provisional degree/diploma or provisional certificate of having passed the MBBS examination issued by the Dean of the College/University in original along with relevant copies be forwarded with this application. The original will be returned with the provisional certificate of registration. 3. Certificate of date of birth 4. Bank Draft for Rs. 500/- (Rupees Five Hundred) in favour of 'Nagaland Medical Council'(non refundable) (For office use) Received the above documents in original ........................ Signature of registered person Name.. ...................................................... Date.. .......................................................