Amendment status not verified — confirm the current text below against the official source.
Bank Draft for Rs 5001- (Rupees Five Hundred) in favour of 'Nagaland Medical Council'(non refundable) (For off~ce use) Received the above documents in original ........................ Signature of registered person Name.. ...................................................... Date.. ....................................................... FORM - 9 FORM FOR CERTIFICATE OF PROVISIONAL REGISTRATION passport photograph attested CERTIFICATE OF PROVISIONAL REGISTRATION This is certifj that .................................................. ..(who has signed in the box son/ daughter of SMSmti.. ....................................... havingpassed the final ................................................ MBBS - examination (Date) from .............................................. (Medical College) affiliated to the University of.. ........................ has been given Provisional Registration under theNagaland Medical Council Act, 2014, for the purpose of practical training (Internship1 .............................. .) in ...................... In witness whereof, the seal of theNagaland Medical Council,Nagaland and the signature of the Registm are herewith e e d . Subject to the provisions of the said Act, this certificate is valid up to.. ............ orthe completion of Internship, whichever is later. This holder shall be entitled to practice medicine in the approved institution for the purpose of such training and for no other purpose. Date. ................................. Signature of Registrar With seal *Institution 1 hospital N.B: This certificate is to be surrendered to the Council at the time of Find Registration. Appendix - B FORMAT FOR PROVISIONALREGISTER OF MEDICAL PRACTITIONERS SI No 1 2 Name Telephone No1 Fax No./€-mail ID 11 Mother's Name 3 Qualification Hospital1 Institution selected for Practical training (Internship) 21 Fathers Name 1 Husbands Name 4 General Degree Gender 5 Date of Birth (ddlmmlyy) 6 Description of Qualifi- cation 12 Medical Degree Name of Medical College attended 22 Description ofQualifi- cation 16 Nationality 7 Institution 13 Initial of Registrar 23 Medical College1 Institution 17 Remarks 24 Categwy (GenerallAPST) 8 Boardl University 14 Year of Qualifi- caton 15 Roll No./ Regis- Won 18 Address Residential Address 9 Permanent Address 10 Board1 University Licensing Body 19 Year of Qualifi- cation 20 Form - 10 Nomination Paper (To be fffled by the Candidate) Bank Draft No .......................... Date ........................ Amount ..................................................................... passport photogmph attested I am registered practitioner of the Nagaland Medical under Registration No.. ................... and hereby offer my candidature for election as Member of Nagaland Medical College, I further declare that I shall work for Nagaland Medical Council Selected.