APPLICATION FORM FOR REGISTRATION OF ADDITIONAL QUALIFICATION(S) [Rule 3(6)]

Uttaranchal Medical Council, Dehradun Stamp of Address of the Council Receipt No. ... Date. ... Bankers's cheque/Bank draft no ... Date. ... APPLICATION FORM FOR REGISTRATION OF ADDITIONAL QUALIFICATION(S) 1. Name of the Applicant: (Surname) ... (Middle name) ... (First name) ... [in Block Letters] : Maiden Name (in case of married women) : 2. Father's Name : 3. Sex: Male / Female 4. Address: Temporary Permanent 5. Date and Place of Birth: 6. Name of Additional Degree, Diploma obtained and University, licensing body with year of obtaining the same. The subject of post graduation(s) should also be indicated. 7. Registration No. in Uttaranchal Medical Council with date Date: (Signature of the Applicant) Note: (1) Copies of relevent additional academic qualifications may be submitted with this application alongwith originals which would be returned after verification. (2) The application form should be properly and neatly filled up. (3) Crossed Bank draft/banker's cheque/or Rs. 100/- (Rupees hundred only) in favour of "Uttaranchal Medical Council, Dehradun" payable at Dehradun should be sent with the application as fee. (4) Only post graduate qualifications recognised by Medical Council of India would be entered in the Register. (5) Entries of additional qualifications as under (4) above would be entered only for those persons who possess a registerable basic medical qualification as included in the schedule to the Indian Medical council Act, 1956.