Form "F"

(see Rule 6)

From of Application for Registration under sub-section (1) of Section 22 of the Madhya Pradesh
Homoeopathy Parishad Adhiniyam,1976.

To,

    The Registrar,
    State Council of Homoeopathy,
    Madhya Pradesh,
    73, Zone-II, M.P. Nagar.
    BHOPAL-462011.

Sir,

                I request that my name may be entered in the state Register of Homoeopathy maintained under the Madhya Predesh,Homoeopathy Parishad Adhiniyam,1976 and that I may be furnished with a Certificate of Registration necessary particulars
are given under.-

1.	Full name	(in Hindi)	.........................................................................................................
	(Maiden name also in case of married woman)	(in English)	.........................................................................................................
2.	Father's/Husband's name	(in Hindi)	.........................................................................................................
		(in English)	.........................................................................................................
3.	Residential address		.........................................................................................................
	(House No., Mohalla, Post Office, Village, District, Pin coad No.)		.........................................................................................................
4.	Professional appointment in Government and post held.		.........................................................................................................
5.	Professional address and place with period.		.........................................................................................................
6.	Date of birth		........................................................................................................
	(In English Calander)
7.	(A) (1) Medical Qualification (Under the Act)		........................................................................................................
	(2) Date on which acquired		........................................................................................................
	(3) University/Board which granted		........................................................................................................
	(4) Oeriod of Education and place		........................................................................................................
	(B) General other than Medical-
	(1) Qualification		........................................................................................................
	(2) Date on which acquired		........................................................................................................
	(3) University/Board/Institution		........................................................................................................
	(4) Place of Education and period		........................................................................................................
8.	The Provisional Registration No. U/s. 24		........................................................................................................
9.	Documents enclosed-
	(1)   For date of birth		........................................................................................................
	(2)   Diploma/Degree		........................................................................................................
	(3)   Certificate of internship		........................................................................................................
	(4)   Fee receipt		........................................................................................................
	(5)   Original Provisional Registration         Certificate		........................................................................................................
	(6)   Professional Affidaivit		........................................................................................................

NOTE:-Please attach the copies of certificates/documents of qualification matriculation/H.S.S.Certificate, duly attested by a Magistrate or a Gazetted officer but provisional registration certificate in original must be attested.

The requisite fee of Rs. 1,500/-for registration through crossed Bank Draft/M.O. in cash is paid. Please see Receipt
No...................................Date............................

 I solemonly declare that all the entries above are true to the best of my knowledge and belief. Enclosed two Pass Port Size photo with application form.

Place.....................                                                                            Yours faithfully

Date.....................

(Name and signature of applicant)

FOR USE OF THE OFFICE OF THE M.P. HOMOEOPATHY PARISHAD

Fee received on................................................

Amount............................................................

 Whether application is complete/incomplete and full fee received.

Order of the Registrar

Signature Incharge Clerk

(Signature Registrar)

Note:- E-Form ( 100 Rs. will be charge with submission of this form)