APPLICATION FOR ... - Travancore Cochin Medical Councils by cuiliqing

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									                      APPLICATION FOR RENEWAL OF REGISTRATION
                TRAVANCORE-COCHIN COUNCIL FOR MODERN MEDICINE

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1.        Name & Address (in block letters)               ::


2.        Father’s Name                                   ::

3.        Date of birth in figures and words              ::

4.        Registration number and date of                 ::
          registration

5.        Qualification                                   ::

6.        Name of the College and University              ::

7.        Year of award                                   ::

8.        Additional qualifications registered            1)
          with date of registration
                                                          2)

                                                          3)

9.        No. of credit hours in CME acquired by          ::
          the applicant in the previous five years

10.       Professional Address                            ::

                                                 Declaration

          I, Dr. ……………………………………………, do hereby declare that the details given
above are true to the best of my knowledge and belief.


Place :                                           Signature :
Date :                                            Name           :
                                              (2)


                                         Instructions

1.   Original Registration Certificate should be surrendered along with the application.

2.   Two passport size colour photograph (attested by a Gazetted Officer on the reverse) should
     be attached.

3.   Self attested copy of CME certificates showing 30 hours of credit in the preceeding 5 years
     should be enclosed.

4.   Fee for renewal is Rs.500/-. A fine of Rs.100/- should be remitted for each year of delay.
     (Fee can be remitted by the special chalan issued by the Council at the SBT Main Branch,
     Thiruvananthapuram or by D.D. from any Scheduled Bank payable at the State Bank of
     Travancore, Thiruvananthapuram, drawn in favour of the Registrar, Travancore-Cochin
     Medical Councils).

5.   Self addressed, stamped cloth-lined envelop (30 cms x 26 cms) should be attached for
     sending the Certificate by Registered Post.


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