| 1. |
Name of the applicant ( in block letter) |
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_____________________________ |
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| 2. |
Father’s Name |
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_____________________________ |
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| 3. |
Address |
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_____________________________ |
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i) Practice |
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_____________________________ |
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_____________________________ |
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_____________________________ |
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_____________________________ |
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ii) Residence/Correspondence |
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_____________________________ |
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_____________________________ |
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_____________________________ |
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_____________________________ |
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iii) Details of employment if any with |
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_____________________________ |
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Designation & name of institution |
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_____________________________ |
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| 4. |
Date of birth in Christian era |
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_____________________________ |
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(in words also) |
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_____________________________ |
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| 5. |
Name and full address of the Ayurveda/ |
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_____________________________ |
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Unani/Siddha institutions attended, with |
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_____________________________ |
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the year of joining and leaving. |
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_____________________________ |
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| 6. |
Name of the Degree/Diploma in Ayurveda/ : |
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_____________________________ |
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Unani/Siddha obtained (UG & PG) with the |
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_____________________________ |
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name of University/Board/Faculty/Examining |
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_____________________________ |
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Body/Institution and Year of passing. |
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| 7. |
Details of Internship |
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_____________________________ |
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_____________________________ |
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| 8. |
Name of state Boards/Councils with which |
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_____________________________ |
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Practitioner Registered |
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_____________________________ |
| 9. |
Regn. Number and Regn. date: |
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_____________________________ |
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_____________________________ |
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| 10. |
I am enclosing herewith the following documents:– |
| (1) |
Photo copy of the Registration Certificate of the State/Board attested by a Gazetted Officer. |
| (2) |
Photo copy of Medical qualification attested by a Gazetted Officer. |
| (3) |
Two passport size colored and unstapled photographs. |
| (4) |
Prescribed Fee of Rs. 1,100/- by Demand Draft in favour of THE CENTRAL COUNCIL OF INDIAN MEDICINE, NEW DELHI |
| D.D.No.____________________Dated_______________for Rs._____________________only. |
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| Place:_____________________________ |
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(Name & Signature) |
| Date:_____________________________ |
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