FORMAT FOR PROVISIONAL REGISTER OF MEDICAL PRACTITIONERS

Appendix - B FORMAT FOR PROVISIONAL REGISTER OF MEDICAL PRACTITIONERS SI No 1 2 Name Telephone No/ Fax No./E-mail ID 11 Mother's Name 3 Qualification Hospital/ Institution selected for Practical training (Internship) 21 Father's Name / Husbands Name 4 General Degree Gender 5 Date of Birth (dd/mm/yy) 6 Description of Qualification 12 Medical Degree Name of Medical College attended 22 Description of Qualification 16 Nationality 7 Institution 13 Initial of Registrar 23 Medical College/ Institution 17 Remarks 24 Category (General/APST) 8 Board/ University 14 Year of Qualification 15 Roll No./ Registration No 18 Address Residential Address 9 Permanent Address 10 Board/ University Licensing Body 19 Year of Qualification 20