FORM-A
[SEE REGULATION 5(i)]
APPLICATION FOR REGISTRATION IN THE
CENTRAL REGISTER OF INDIAN MEDICINE

1. Name of the applicant (in block letters) Surname Name
2. Father's Name    
3. Address :
(a) Present
(b) Permanent
   
4. Date and place of birth in Christian era (in words also)
5. Present Occupation.
6. Qualification (from Matric or an equivalent examination and onwards) obtained yearwise.
7. Name and full address of the Ayurveda/Unani/Siddha institutions attended, with the dates of joining and leaving.
8. Name of the Degree/Diploma in Ayurveda/Siddha/Unani obtained with the name of University/Board/ Faculty/Examining Body/Institution and Year of passing.
9. Whether he/she has undergone practical training before or after obtaining degree/diploma in Indian Medicine as an internee in hospital ?
10. Is he/she registered with any State Board of Indian Medicine ? If yes, the name of the Board with which regis­tered and number and date of registra­tion, Reasons for applying to the Central Council of Indian Medicine for direct registration may be given.
11. Is he/she a citizen of India :

(a) by birth
(b) by domicile


FORM-B
[SEE REGULATION 5(4)]

1. Certificate Number
2. Name
3. Father's Name
4. Recognised Medical qualification
5. Date & Place of Registration
6. Address;
Present:
Permanent:
7. Remarks :
It is hereby certified that this is a true copy cf the entry of the above mentioned practitioner in the Central Register of Indian Medicine.

NEW DELHI
Date :

Registrar
INSTRUCTIONS
1. The Registered practitioners are requested to send to the Registrar immediately notice of any change in their regis­tered address and also to answer all enquiries that may be sent to them by the Central Council of Indian Medicine from time to time.
2. No fee is charged for alteration of address.
3. All persons registered with this Council are legally quali­fied to practice Indian Medicine in any State.



FORM-C
[SEE REGULATION NO- 5(5)]

REQUEST FOR REGISTRATION OF ADDITIONAL QUALIFICATIONS IN
THE CENTRAL REGISTER OF INDIAN MEDICINE

1. Name of the practitioner as given in the Central Register of Indian Medi­cine.
2. Address :
Present:
Permanent:
3 Qualification with name of institution and year of obtaining the same.
4 Name of the State Board with which registered and registration number and date.
Additional qualification (s) subsequently obtained with the name of University/Board/Faculty /Examining Body and year of obtaining the same. (Attested copies of the certificates should be enclosed.)


Signature of the candidate
I solemnly affirm and declare that above entries are correct.
It is requested that my additional qualification may please be entered in the Central Register of Indian Medicine.

Date :
Signature of the applicant. :



FORM-D
[SEE REGULATION (6)]
APPEAL FOR RESTORATION OF NAME IN THE STATE REGISTER



To,
The Secretary to the Government of India,
Ministry of Health and Family Welfare,
New Delhi-110001.

1.I the undersigned................................... (Full name in block letters beginning with Surname) holding qualifications of............................... (State the qualifications) do declare at the following are the facts of my case on which I seek restoration of my name in the State Register.

2. My name was duly registered in the State Register of.................. (name of the State) having registration number...................... dated .................

3. At an enquiry held on the...........day of.......... by the State Board, my name was directed to be removed from the State Register and the offence for which the Board directed the removal of my name was .................. (use separate sheet for details if necessary) (Attested copy of the Orders of the State Board to be enclosed).

4 . Since the removal of my name from the State Register, have been residing at ............... and my occupation has been .............................................

5. I have not made any appeal to the State Government in this matter.
6. The grounds for the present application are below:
(i)
(ii)
(iii)
7. The prescribed fee of Rupees Twenty-five, has been deposited by Bank Draft No............dated............payable to the Secretary, Ministry of Health & Family Welfare, New Delhi.
8. I request that orders may be passed for restoration of my name in the State Register of ..................(State)

Place........
Dated....

Signature
Full name and address