Naharlagun Male Female 0 0 0 0 Receipt No Date (For office use) To, Affix passport size photograph attested The Registrar, Arunachal Pradesh Medical Council, Sir, I hereby request that my name and other particulars mentioned below may be entered in the State Register of Arunachal Pradesh Medical Council as required under section-10 of Arunachal Pradesh Medical Council Act 2004 (Act No.4 of 2004). Name of the Applicant (in block letters) 1. 2. Father's/ Husband's Name 3. Mother's Name 4. Gender 5. Nationality 6. Date of Birth (date, month, year) 7. Address (a) Residential Address (b) Permanent Address (c) Professional Address 8. Telephone No./ Mobile No./ Fax No./ E-mail ID 9. Category General/ APST Published on National Portal of India (india.gov.in) Application form for Direct Registration Arunachal Pradesh Medical Council (See Rule 25, 26) FORM-1 Yes No Yes No 10. Qualifications : (a) General Degree Sl. No. Description of Qualification Name of the School/ College/ Institution Name of the Board/University Year of Qualification 1. 2. 3. 4. (b) Medical Degree Year of Qualification/ completion of Internship Name of the University/ Description of Qualification Name of the College/ Institution Sl. No. Licensing Authority 1. 2. Details of Internship (include separate sheet, if require) : 11. 12. MCI Registration No. & Date (if any) 13. (a) Registration No. & Date, if any in other State Published on National Portal of India (india.gov.in) Authority under whom Registered 14. (a) Bank Draft No. & Date (b) Draft Prepared from (Bank) I submit herewith original certificates for verification and submit attested copies of the same certificates:- If registered else where (MCI and other State) (a) (i) Birth Certificate/ Matriculation Certificate/SSC Exam certificate with date of birth. (ii) MBBS Degree/ Post Graduate Degree/ Diploma/ Post Doctoral Degree/ any other. (iii) State Medical Council/ Medical Council of India Registration Certificates with MBBS Qualification. (iv) Original Internship Completion Certificate. (v) Other evidence in support of my having obtained the qualification which I possess. (vi) No Objection Certificate from State Medical Council where earlier registered. (vii) Three recent passport size photographs with name and signature at the backside. (viii) Bank Draft Rs.1000/-(Rupees one thousand) in favour of "Arunachal Pradesh Medical Council" payable at Naharlagun (non-refundable). (b) In case of fresh registration (i) Birth Certificate/ Matriculation Certificate/SSC Exam certificate with date of birth. (ii) MBBS Degree/ Post Degree/ Diploma/ Post Doctoral Degree. (iii) Original Internship Completion Certificate. (iv) Other evidence in support of my having obtained the qualification which I possess. (v) Three recent passport size photographs with name and signature at the backside. (vi) Bank Draft Rs.1000/-(Rupees one thousand) in favour of "Arunachal Pradesh Medical Council" payable at Naharlagun (non-refundable). 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 Arunachal Pradesh Medical Council and Indian Medical Council and by the Rules of Arunachal Pradesh Medical Council. Date Signature of the Applicant (for office use only) Received the above documents in original Signature of registered person Name Date Published on National Portal of India (india.gov.in) (b)
