APPLICATION OF RESTORATION OF NAME IN THE REGISTER

FORM - 7 APPLICATION OF RESTORATION OF NAME IN THE REGISTER Receipt No.. Date ................................. (For office use only) To, The Registrar, Nagaland Medical Council, photogmph attested Sub: Restoration of name in the Register. Sir. 1. I , .............................................. the undersigned ............................................... ....................................... (name and address) holding qualification of ........................................................ do solemnly declare that the following are *facts of my case on which I seek restoration of my name in the Register. 2. My name was duly registered in the State Register of ............................... .................................. Having registration number .................................... (Name of the State) ....................................................... D a d ................................... 3. My name was duly registered in the State Register of Nagaland Medical Council on ................................................ Having registration number ......................................................................................................................... 4. At an enquiry on the ................................ Day of ................................. : by the Council/Board/Committee of .......................................... my name was directed to be removed from the State Register and the offence(s) for which the Council/ Board/Committee of ............................................ directed removal of my name was/were.. .............................................................................................. 5. Since the removal of my name from the Register, I have been residing at ................................................................................................ And my ........................................................................................ occupation has been 6. It is my request that my name be restored in the Register of .................... ............................................................................................................... State. 7. The grounds for the present application are: 0 CW 8. The prescribed fee of Rs. 1,000/- (Rupees One Thousand) deposited by Bank draft No. ................................... Dated.. ................................. In favour of Arunachal Pradesh Medical Council 9. I request that orders may be passed for restoration of my name in the State Register of .......................................... (State) 10. I submit three recent passport size photographs. 11. I submit Nagaland Medical Council Registration Certijicate in o r i g i n a l . Declared at ........................... Before.. ............................... Signature (for office use only) Received the above documents in o r i g i n a l . ............... Signature of registered person Name.. ............................................. Date ................................................ *(Instructional): All facts and the grounds on which the application is made should be clearly and concisely stated. Use separate sheets if necessary)