APPLICATION FOR REGISTRATION OF DOCTOR FOR ISSUANCE OF FORM-1A (PHYSICAL FITNESS CERTIFICATE TO LICENCE APPLICANT) UNDER MV ACT 1988

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UNDERTAKING BY THE APPLICANT

  • The particulars furnished above are true & correct to the best of my knowledge. In case anything found wrong then I shall be legally liable.
  • I shall issue the physical fitness certificate to the licence applicant as per the Indian Medical Council (Professional Conduct, Etiquette and Ethics), Regulations, 2002 & the Odisha medical registration act, 1916.
  • In case of any deviation in issuance of physical fitness certificate then I shall be held responsible.
  • I have enclosed the self-attested copy of following documents with this application.
    • 1. COPY OF MEDICAL DEGREE QUALIFICATION CERTIFICATE
    • 2. COPY OF MC1/OCMR REGISTRATION CERTIFICATE
    • 3. COPY OF ID PROOF AS MENTIONED IN SL NO-6 & 7
    • 4. RECENT PASSPORT SIZE COPY

Full signature of the applicant