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ToPUNJAB MEDICAL COUNCILSikhiya Bhawan ,7 th Floor, E-Block, phase-8, Mohali0172-2210167,2230240,2230241,Fax No.2210166APPLICATION FORM FOR RENEWAL OF REGISTRATION& 2 nd OR SUBSEQUENT RENEWAL OF REGISTRATIONThe Registrar,Punjab Medical Council.MohaliSir,I am registered with Punjab Medical Council vide Regd.No.___________ dated___________ It is requested that my registration may please berenewed for the period of 5 years. The information necessary for registration is specifiedbelow :-PARTICULARS1. Applicant’s name in full _________________________________________2. Father’s Name _________________________________________3. Date of Birth _________________________________________4. Working places __________________________________________________________________________________5. Mobile No. _________________________________________6. E-mail. _________________________________________7. Qualification _________________________________________(alongwith Name of MedicalCollege & University)___________________________________________________________________________________________________________________________8. Permanent Registration No. _________________________________________9. What is your Nationality…INDIAN/FOREIGN ?IF INDIAN. Your passport number if any. Date of issue………………..ValidUpto………………………………place of Issue. Name of your Mother……………………………………………………………10. …..if Foreign(.a)Name of Country. Date of issue…………place of issue…………….Date of Expiry .(please note that practitioners holding foreign passports will have to haveadditional OCI/PIO card)to be eligible for registrations.All the Information should be true & correct. A copy of attested Document has to beenclosed along with main application.Any remarks_________________________________________Bank Draft No. …………………… Dated ……………… Amount…………………ATTESTEDPHOTOPASTEHEREDate___________Signature of ApplicantFOR OFFICE USE ONLYRegistration No. __________B.D. Receipt No.__________Dispatch No. ____________Dated ___________20Dated ___________20Dated ___________20`All formalities completed. May renew his/her Name.SuperintendentSubmitted for approval & signature.Registrar
