DELHI MEDICAL COUNCIL

Room No. 368, 3^rd Floor, Pathology Block

Maulana Azad Medical College, Bahadur Shah Zafar Marg,

New Delhi – 110 002  Telefax : 23234416  Phone : 23237962, 23235177

Email : delhimedicalcouncil@vsnl.net

Website : delhimedicalcouncil.nic.in

Receipt No. __________

Date ___________

       Bank Draft No. _______________Date _____________

APPLICATION FORM FOR RENEWAL OF REGISTRATION

1.    Name of the Applicant (In block letters)

- First Name :                                              Middle Name:                                                    Surname :

2.    Father’s Name :

3.    Gender :   Male / Female

4.    Address (Mailing Address):                                                          Permanent Address:

5.    (a) Telephone Number :                            (b) Mobile No:                           (c) E-mail Address :

6.    Details of Additional Qualifications for incorporation, if any :

7.    Delhi Medical Council Registration Certificate No :  _______________ dated ___________  surrendered  and attached herewith.

8.    Present Occupation with address :

I submit herewith original certificates for verification and submit copies of the following certificates : -

a)            Three recent passport size photographs with name and signature at the backside.

b)            Delhi Medical Council Registration Certificate

c)            Post-Graduate Degree/Diploma/Post-Doctoral Degree Certificate

I hereby submit a Bank Draft No. ………… dated ………..drawn on ………………………... Bank for Rs. 1,000/- (Rupees One Thousand Only) as non-refundable fee in favour of “Delhi Medical Council” payable at New Delhi.

Date :                                                                                                         Signature of the Applicant

D E C L A R A T I O N

I solemnly affirm & declare that the above entries made by me are correct, and undertake to abide by the Code of Ethics of Delhi Medical Council and Medical Council of India and by the Rules of Delhi Medical Council.

   Date :                                                                                                             Signature of the Applicant

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( For Office use only)

S.No. of  Registration Certificate Renewed  _______________________ dated.

Acknowledgement of receipt of Registration Certificate.

Received the above document in original.

Signature of registered person _____________________

Name _________________________

Date _________________