FORM - VI RULE (9)
NATIONAL BOARD OF ALTERNATIVE MEDICINES
FORM OF APPLICATION FOR REGISTRATION
GRADE
Applicant's Name : ______
Permanent Address : ______
______
______Pin Code______
Phone/ Mobile (if any) :______
To
THE REGISTRAR,
National Board of Alternative Medicines,
60, Mela Chetty Street, Kuttalam - 609 801,
Tamil Nadu, India.
Sir,
1. I have the honour to request that my name may be registered under the rules for the registration of Alternative Medical Practitioners and that I may be furnished with a Certificate of Registration.
2. The information necessary for registration is furnished on the reverse.
3. The certificates required are also furnished in the prescribed forms.
4. The Documents required for Registration are enclosed herewith as per noted in the prospectus.
4. The Xerox copy of Diploma / Degree / Certificate, which I possess is forwarded herewith.
5. The Registration fee Rupees ...... is send herewith by Demand Draft / Money Order.
D.D./ M.O No. : ______Dt ______
Bank / PO : ______Dt ______
I hereby declare to abide by the code of Medical Ethics.
Date : Yours faithfully,
Station :
(Signature) ______
Fees Should be made in favour of the
President, National Board of Alternative Medicines, Kuttalam - 609 801.
P.T.O
.2.
1. Applicant's Name in full ...
(in block letters)
2. Father's / Husband's Name ...
3. Residential address in full ______
(including PIN CODE) ... ______
______
______Pin Code ______
4. Phone / Mobile (If any) ... ______
5. Sex ... MALE / FEMALE
6. Date of Birth and Age ...
(Proof to be furnished)
7. Blood Group ...
8. Identification Marks any one ...
9. Medical Qualification, if any (Tick) ... Experience / Diploma / Degree / PG Degree
10. System of Medicine being practised ... Alternative Medicine / Indo-Allopathy /
Electro - Homoeopathy / Acupuncture
11. Practical Experience ...
12. Places and periods of Continuous
Private Practice ...
13. System of Medicine in which
registration is required ... Alternative Medicine / Indo - Allopathy
Electro - Homoeopathy / Acupuncture
14. Whether applied for registration
before either to this council or to
any other registering body and if so,
the result of such application ...
15. Any further information ...
16. In which Grade to be regd. ... A Grade / B Grade / C Grade
17. Village Taluk District State
......
Date : Signature of the applicant.
1. I have read and understood the rules for the registration of Alternative Medical Practitioners and shall abide by them.
2. I shall also abide by the rules and code of Medical ethics laid down by the National Board of Alternative Medicines from time to time.
Date : Signature of the applicant.
Station :
CHARACTER CERTIFICATE
I hereby certify that the applicant Thiru / Thirumathi / Selvi ______Son / Daughter / Wife of ______residing at ______is personally known to me. As far as my knowledge goes he bears a good moral character.
Date : Sign with Seal
Station :
CHARACTER CERTIFICATE
I hereby certify that the applicant Thiru / Thirumathi / Selvi ______Son / Daughter / Wife of ______residing at ______is personally known to me. As far as my knowledge goes he bears a good moral character.
Date : Sign with Seal
Station :
This certificate is not necessary for Diploma / Degree / PG Degree holders.
EXPERIENCE CERTIFICATE
On the basis of facts known after due enquiry, I certify that Thiru / Thirumathi / Selvi ______Son / Daughter / Wife of Thiru ______resident of ______aged about ______years and whose signature is given below has been practising ______System of Medicine since ______. He / She is fully conversant with the job, and Medicine and nothing is wrong to debar him / her from the registration as Registered Medical Practitioner.
Signature of the certifying Officer
Signature of the Candidate.
Name in Full :
Seal
Date :
Designation :
Date :
N.B. : This certificate should be signed by Tahsildar or M.B.B.S. Doctor or Gazetted Officer or Registered Medical Practitioner or M.L.A.
This certificate is not necessary for Diploma / Degree / PG Degree holders.