[see Rule 4(1)]

APPLICATION FOR RENEWAL

To,

The Registrar,
M.P. State Council of homoeopathy,
73,Zone-II, M.P. Nagar,
Bhopal-462011.

My name is entered in the State Rrgister of Homoeopathy under the provisions of M.P. Homoeopathy Parishad Adhiniyam,1976 at No.....................and Registration Certificate bearing No.........................has been issued to. For continuing my name in the said Register te certificate in original alongwith the fee Rs.300/-in cash/BankDraft.................... (Name of Bank.................................................and three pass part size photos are enclosed.

2. I have falled to apply for renewal and continuation of my name in the State Register of Homoeopathy,the renewal fee of Rs. 300/- and additional late fee of Rs. 50/- per month subject to be maximum of Rs. 300/- Total Rs...............................
in cash/through Bank Draft No........................................(Name of Bank)...............................................are enclosed.

3.	(1) Name of Applicant	(In Hindi)	..........................................................................
		(In English)	..........................................................................
	(2)Name of Father/Husband		..........................................................................
	(3)Place of practice		.........................................................................
			.........................................................................
	(4)Date of Birth (In English Calander)		.........................................................................
			Date..............Month....................Year.................
	(5)Qualification-	(a) General Medical	.........................................................................
		(b) Additional qualification if added	.........................................................................
	(6)Qualification acquired on date................Year.................		.........................................................................
	(7)University/Board from-General where qualification acquired		........................................................................
	(8)Registration No. and date		........................................................................
			........................................................................
	(9)Punished by Court in or professional Mis-conduct		any criminal...................................................... Case No........................................................... Nature of..........................................................
			Punishment....................................................... Name of court...................................................
	(10)Renewal fee		In cash............................................................
			Bank draft No...................................................
			Name of Bank..................................................
			Late fee.............................................for month
			Rs. (Total).......................................................

Certified that the information furnished above is true to the best of my Knowledge and records. The attested copies of testimonials are enclosed

(Name of applicant
and Signature)

FOR OFFICE USE

Certified that-

(1)

The Renewal fee Rs...........................................................late fee Rs......................................................

........................................................R. No..............................................................Date........................
.......................................................................has been received.

(2)

The certificate in original has been received with the application.

(3)

The entry of Renewal has been made on ........................................(Page No.) in the Registrar.

(Signature of Incharge)                                                                                                (Signature of Registrar)

The certificate of Registration has been sent vide D.No. ..............................................Date..........................................

by Registered post R. No. ..........................................................Date..............................................................

(Signature of Despatcher)