Price: Rs. 200.00, (FOR OFFICE USE ONLY) Additional Registration Certificate Receipt No.: Sr. No. Date : ADDITIONAL REGISTRATION FORM PROFORMA-S MADHYA PRADESH MEDICAL COUNCIL: BHOPAL APPLICATION FORM OF ADDITIONAL REGISTRATION U/S 13 OF THE MP. AYURVIGYAN PARISHAD ADHI. 1987 (Before filling this Application Form Please read the important instructions) To, ‘The Registrar Madhya Pradesh Medical council F-7, Sanchi Complex, Opp. Board Office BHOPAL (M.P.) 462016 PH: 0755-2767786, 2551568 | request you to enter my following Additional Qualification(s) in the State Medical Register against my name under the provisions of Madhya Pradesh Ayurvigyan Parishad Adhiniyam, 1987 and to give me a certificate of Registration. The particulars of my medical qualification (s) are given below: (THE APPLICATION FORM MUST BE FILLED IN BLOCK LETTERS ONLY) 1, NAME: (Surname First) (MR. /MISs/ MRS) 2, FATHER’S NAME: 4, PERMANENT REGISTRATION NO. of MPMC: DATE NAME OF THE COUNCIL: 5. P. G. MEDICAL QUALIFICATION (s) (Only Recognized Qualification):~ Ss. P. G. Qualification Month & University Medical College No. Year of Exam 6. A Bank Draft No. Dated of Rs. Name of Bank | is being enclosed here with towards my Registration Fees. 7. Present Address: Distt. State Pin, Mob. E-mai 9. Thereby solemnly declare that the above particulars furnished by me in this application form are true to the best of my knowledge and belief. Sign. of the Applicant (CHECKER) Contd...2 |NAME OF THE APPLICANT. RECEIPT NO. 10. A Bank Draft No. Dated of Rs. Name of Bank in favor of _ is being enclosed here with towards my Verification Fees. (FOR OFFICE USE ONLY) 1. Received all the original documents from the office of the Registrar M. P. Medical Council, Bhopal Dated: (Name and Signature of the Depositor) 2. The application form has been checked and found correct along with the requisite documents, Dated (CHECKER) 3. Registration Fee of Rs. has been received vide Money Receipt No Dated: . (ACCOUNTANT) 4, Confirmation of passing of P. G. Degree/Diploma received from the concerned Universities / College or granted permission on note-sheet and found eligible for issuing ADDITIONAL Registration Certificate. Dated: (IN-CHARGE REGN-1 SECTION ) 5. Entered the Specified Additional Medical Qualification(s) in the State Medical Register on and Additional Registration Certificate Sr. No. signed. (WRITER) (REGISTRAR) 6. Additional Registration Certificate despatched on vide despatch No through Regd AD. / Personally / Authorised person (DESPATCH CLERK) Contd... 3RECEIPT No. MPMC/ (Extra Signature of the Applicant) (Extra Signature of the Applicant) MADHYA PRADESH MEDICAL COUNCIL BHOPAL PH: 0755-2767786, Website: www.mpmedicalcouncil ADDITIONAL REGISTRATION FORM DEPOSIT RECEIPT RECEIPT No. MPMC/ Received application form of Dr. along-with the requisite documents and (i) Bank Draft for Registration fee of Rs. 5 (ji) Bank Draft for Verification fee of Rs. for Additional Registration. Bhopal, Dated (Signature of Receipt clerk) (AUTHORITY LETTER) L hereby authorize Mr. / Miss./Mrs. (Whose usual signature is being attested by me here as under) to receive my Additional Registration Certificate and the other originals (if any) from office of the Registrar, Madhya Pradesh Medical Council, Bhopal. Dated: (Sign. of the Authorised Person) (Sign. of the Applicant) Contd....410. aa (IMPORTANT INSTRUCTIONS FOR THE APPLICANT) The application form must be filled in BLOCK LETTERS only by the applicant in his/her own hand-writing ‘The Application Form with any Overwriting, Cutting, Xerox and with any missing of the required information will not be accepted for Registration Printed copy of the Application form will be accepted only. The applicant should remember that his / her name entered in the Application Form must exactly correspond with the name mentioned in his/her Registration Certificate. All the Original documents will be returned to the applicant after doing the needful by Registered Post or in person as the case may be. Application Form is accepted in the office between 11:00 am to 3:00 pm on working days. Issuance of the Registration certificate takes two months time after receiving confirmation, Registration Certificate can also be received in person on any working day between 3.00 pm to 5.00 pm on submission of the Form Deposit Receipt by the applicant after the due-period. In case of any Representative of the applicant an AUTHORITY LETTER will also be required in the prescribed pro-forma as given in this application form. ‘The applicant is required to submit / enclose the following documents in ORIGINAL with its photocopy. (i) Permanent Registration Certificate self attested, (1 Photocopy) Gi) Post Graduate DEGREE/Diploma from the concerned University. (2 Photocopy) ii) Any Authentic document of your medical college for verification of Name of College (1 Photocopy) (iv) Passing Certificate of qualification from the Dean of the concerned Medical College. (1 Photocopy) (only for the students who possessed P.G. qualification from the Medical Colleges of M.P, if available) (¥) The Prescribed fee of Rs.2000.00 cach degree + Cost of Application form Rs. 200.00 for Additional Registration + Late fee (if any) will be accepted only through a Crossed Bank Draft of NATIONALISED BANK in favour of the “Registrar, Madhya Pradesh Medical Council, Bhopal” payable at BHOPAL. Fees in Cash/by Money Order/by Postal Order / by Cheques will not be accepted. (vi) The amount of fee for obtaining any Confirmation as fixed by the concerned university! institution, shall be payable by the applicant separately. The late fee shall be payable after the expiry of 3 months period from the month of final examination as mentioned below:- Tate fees payable wie. 1” November, 2018 + IfDiploma/Degree already registered in State Medical Council other then MP. Medical Council, no late fee chargeable. ‘+ Only one late fee will be applicable for diploma/degree passing of final exam of diploma /degree which ever earlier in the case may be. ‘+ Period laps between the month & year of final exam of Diploma/P.G.Degree and submission of application for Additional Registration- Upto 03 months Nil 103 to 06 months 'RS2,000.00 ‘06 to 12 months Rs.5,000.00 ‘Above 12 months Rs.10,000.00neq weer safes ofee, store MADHYA PRADHESH MEDICAL COUNCIL, BHOPAL F-7, Sanchi Complex, Opp. Board Office, Bhopal (MP) — 462016 Office : 0755- 2767786, Fax -2551568, E-mail: [email protected] affix a passport size colour photograph duely attested/varified by Dean/Principal Se Signature of applicant {in box above) Signature of verifying officer with stamp De ee CERTIFICATE TO BE ISSUED BY DEAN/PRINCIPAL Certified* that Dr.. S/o Shri has passed MD/MS/DM/MCh/Diploma In (subject). from this Medical College (name of college)... Roll No ...passed out in the year. admitted in the year. This is also certified that in The aforementioned Dr. : S/o has under taken the training on the Medical Council of India recognized seat. A duely verified copy of Degree/Diploma is being enclosed herewith. (* This certificate is to be granted to the candidate who has undertaken post graduate training from Medical Council of India recognised seat only) Signature with stamp Dean/Principal1 2. I have obtained additional qualification i.e. Appendix —A Format of Affidavit for submitting along-with Application for Additional Registration (Notarised AFFIDAVIT on stamp paper of Rs. 50.00 denomination) AFFIDAVIT 1, Dr. . ves age years s/o r/o do hereby solemnly affirm as under:- My MBBS qualification is registered with M. P. Medical Council, vide no. From Medical College (name). Affiliated to University (name). during Period from and that my additional qualification is a MCI recognized qualification. 3. I declare that documents which I have submitted along with my application for registration are genuine and true. 4. I undertake that documents and declarations submitted by me if found false, fabricated or otherwise tampered with, then Council shall, cancel my registration of additional qualification and shall proceed for taking action against me in accordance with law. Deponent VERIFICATION Lr. eee ... do hereby verify that contents of Para 1 to 4 of affidavit are true to my personal knowledge. Verified at - on this .......... Day of .........20 Deponent