Amendment status not verified — confirm the current text below against the official source.
I submit Nagaland Medical Council Registration Certijicate in on@. Declared at ........................... Before.. ............................... Signature (for office use only) Received the above documents in o r i d . ............... Signature of registered person Name.. ............................................. Date ................................................ *(Instructional): All facts and the grounds on which the application is made should be clearly and concisely stated. Use separate sheets if necessary) APPLICATION FOR PROVISIONALREGISTRATION .................... Receipt No.. Date. ............................. (For office use) To, The Registrar, Nagaland Medical Council. Sub: provisional Registration. photogmph attested Sir, I hereby requestthat my name and other particulars mentioned below may be entered in the State Provisional Register of Nagaland Medical Council as required under section of the Nagaland Medical Council Act 2014. Name of theApplication(b1ock letters) Father's 1 Husband's Name Mother's Name Gender Date of Birth (date, month, year) Nationality Category (General /APST) Address a. Residential Address b. Permanent Address c. Professional Address Telephone No./MobileNo./Fax No./Email ID Details of Qdiication a) General Decree: b) Medical Degree: S1. No 1 1. Name of the Institution where applicant has been Selected for practical training (whether the Hospital Or Institution) where such training is to be undertaken is recognized by the Medical Council of India Description of QuaMcation S1 No.