APPLICATION FOR REGISTRATION OF DOCTOR FOR ISSUANCE OF FORM-1A (PHYSICAL FITNESS CERTIFICATE TO LICENCE APPLICANT) UNDER MV ACT 1988
RTO NAME :
1. NAME :
2. FATHER'S NAME :
3. ADDRESS :
AT :
PO :
PS :
DIST :
PIN :
Attach a recent passport size photo with sign across
4. MOBILE NO :
(10 digit only)
5. ALTERNATE/OFFICE NUMBER (If any)
(10 digit only)
6. ID PROOF :
AADHAR/
PAN CARD/
DRIVING LICENCE
(
please select
)
7. ID PROOF NUMBER :
8. MCI/OCMR REGISTRATION DETAIL :
A. REGISTRATION NO :
B. ISSUEING STATE :
9. MEDICAL QUALIFICATION DETAILS :
10. CLINIC NAME (if any) :
11. CLINIC ADDRESS :
AT :
PO :
PS :
DIST :
PIN :
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
Date :
Full signature of the applicant
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