Application Form
Application for issue of Enrolment Certificate


1. Name of the applicant ( in block letter) : _____________________________
       
2. Father’s Name : _____________________________
       
3. Address : _____________________________
  i) Practice :

_____________________________

      _____________________________
      _____________________________
      _____________________________
  ii) Residence/Correspondence :

_____________________________

      _____________________________
      _____________________________
      _____________________________
  iii) Details of employment if any with : _____________________________
      Designation & name of institution   _____________________________
       
4. Date of birth in Christian era : _____________________________
  (in words also)   _____________________________
       
5. Name and full address of the Ayurveda/ : _____________________________
  Unani/Siddha institutions attended, with   _____________________________
  the year of joining and leaving.   _____________________________
       
6. Name of the Degree/Diploma in Ayurveda/ : : _____________________________
  Unani/Siddha obtained (UG & PG) with the   _____________________________
  name of University/Board/Faculty/Examining   _____________________________
  Body/Institution and Year of passing.   _____________________________
       
7. Details of Internship : _____________________________
      _____________________________
       
8. Name of state Boards/Councils with which : _____________________________
  Practitioner Registered   _____________________________
9. Regn. Number and Regn. date: : _____________________________
      _____________________________
   
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.
       
Place:_____________________________   (Name & Signature)
Date:_____________________________