08/19/2018

mci APPLICATION FORM FOR PROVISIONAL/ PERMANENT REGISTRATION FOR INDIAN NATIONALS HAVING QUALIFIED FROM FOREIGN INSTITUTIONS)

By Live Dr - Mon Jun 14, 1:55 pm

Form – MCI-06
1
MEDICAL COUNCIL OF INDIA
Pocket – 14, Sector – 8, Phase-I, Dwarka, New Delhi – 110 077
Phone : 011-25367033,25367035, 25367036,
Email : mci@bol.net.in, Website : http://www.mciindia.org
APPLICATION FORM FOR PROVISIONAL/ PERMANENT REGISTRATION
FOR INDIAN NATIONALS HAVING QUALIFIED FROM FOREIGN INSTITUTIONS)
(Please read the instructions carefully as given in Appendix-I before filling the form)
Application for Registration: Provisional Permanent
1. NAME OF THE APPLICANT
(BLOCK CAPITAL LETTERS)
2. Sex: Male/ Female.
3. FATHER’S NAME
(BLOCK LETTERS)
4. DATE AND PLACE OF BIRTH
(a) AGE (AS ON 31ST DEC. OF 1ST YEAR MEDICAL COURSE). Years Months Days
5. ARE YOU A CITIZEN OF INDIA
(a) BY BIRTH OR
(b) BY DOMICILE
IF (b) STATE THE DATE OF BECOMING
INDIAN CITIZEN.
6. PERMANENT ADDRESS —————————————————————————–
——————————————————————————————–
7. PRESENT CORRESPONDENCE ADDRESS ———————————————————————
(WITH PHONE NO AND EMAIL ID) ——————————————————————–
8. CATEGORY (GENERAL OR RESERVE i.e. SC/ST/OBC)
9. DETAILS OF EDUCATIONAL QUALIFICATIONS:-
10TH
CLASS/
MATRIC/
HIGH
SCHOOL
• School Name & Address
……………………….
……………………………………………………….
……………………………………………………….
• Board Name & Address
………………………..
……………………………………………………….
……………………………………………………….
* Roll No. & result ………….…….
* Certificate No. & Date ………………………………..
* Date of Passing ……………………………………….
* Marks (Obtained/Total) .………………./……………..
* Percentage ……………………………………………..
Affix
attested
front view
Photograph
Pass Fail
Form – MCI-06
2
11th CLASS
• School Name & Address
………………………
……………………………………………………….
……………………………………………………….
• Board Name & Address
………………………
……………………………………………………….
……………………………………………………….
* Roll No. & result …………..…………
* Certificate No. & Date ……………………………………
* Date of Joining ………………….………………………..
* Date of Completion …………………..…………………
* Subjects ……………………………………………….
* Marks (Obtained/Total) ………………../……………..
12th
CLASS/
Intermediate
or 10+2
• Board Name & Address ………………………
….….………………………………………………
…………………………………………………….
• Roll No……………….……………………
• Date of Joining ………………………………
• Date of Passing …..……………………………
• School Code No. ………………………………
Subjects Marks
Total
Marks
obtained
% Result
Pass/Fail
English
Physics
Chemistry
Biology
Grand
TOTAL
10. B.Sc. or any other University Examination. (if any) as prescribed in Council’s Regulation on Graduate
Medical Education,1997:
• College Name & Address ……………………………….…………………………………………………..………….
• University ….……………………………………………………………………………………………………………..
……….……………………………….………………………Roll No…….………………….……………….………….
• Date of Joining……………..…. Date of Passing …..…………………Examination Passed…………………….
Subjects Maximum Marks
Theory Practical
Marks Obtained
Theory Practical
% Result Pass/Fail
Grand Total
11. MEDICAL QUALIFICATION
Name & address of Institute Address of SENTRALNIYA OVIR
(Registration Deptt.- OVIR)
(Ministry of Foreign Affairs
or Interior Ministry )
City.
Registration
Number/
(OVIR
NO.)
Valid
from
Valid
upto
MEDIUM OF INSTRUCTIONS/COURSE………………………………………………….
Pass Fail
Form – MCI-06
3
Yes No
12. HAVE YOU DONE ANY PART OF YOUR MEDICAL COURSE IN INDIA, OR ANY COUNTRY OTHER THAN
WHERE YOU HAVE OBTAINED MEDICAL DEGREE AS MENTIONED IN COLUMN 11 , IF YES, ITS DURATION
AND LOCATION
13. PASSPORT DETAILS No. .…………………….. Date & Place of issue .………………………
Address as on Passport …………………………………………………………………………………
(a) Date of leaving India————————
(b) Date of returning to India———————–
14. DID YOU EVER CHANGE/LOSS THE PASSPORT – DUE TO ANY REASON:-
If yes, please give reason for change of passport ……………………………………………
Previous Passport No ………………….. Date & Place of Issue ………………………………………………
Address on Previous Passport ……………………………………………….……………………….
FIR Number in respect of lost Passport ..……….………………………………………………
15. SCREENING TEST PARTICULARS:
1. Date of Passing:…………………………………
2. Roll No.:………………………………………….
16. INTERNSHIP TRAINING PARTICULARS
1. Date of Training:…………………………………
2. Institution of Training…………………………….
17. NAME OF THE MEDICAL DEGREE/ DIPLOMA
OBTAINED AND UNIV./ LICENSING BODY
WITH THE YEAR OF OBTAINING THE
QUALIFICATION.
18. (a) WHETHER S/HE HAS UNDERGONE
PRACTICAL TRAINING BEFORE OR AFTER
OBTAINING THE MEDICAL QUALIFICATION
REQUIRED BY THE RULES OF THE CONCERNED
FOREIGN COUNTRY, GIVE DETAILS.
(b) IF NOT, THEN HAS S/HE UNDERGONE
THE PRESCRIBED TRAINING IN AN APPROVED
HOSPITAL IN INDIA, GIVE DETAILS.
19. WAS ANY MEDICAL COLLEGE/SCHOOL IN INDIA
ATTENDED BEFORE DEPARTURE FROM INDIA,
(GIVE NAMES OF PERIOD OF STUDY
UNDERGONE AND EXAMINATION PASSED).
20. IF THE LANGUAGE OF STUDY IN THE COUNTRY
BE OTHER THAN ENGLISH, PLEASE INDICATE IF
IT WAS STUDIED IN INDIA BEFORE DEPARTURE OR
WAS STUDIED IN THAT COUNTRY.PLEASE INDICATE
THE TIME TAKEN FOR THAT STUDY AND
WHETHER ANY EXAMINATION WAS PASSED.
Yes No
Form – MCI-06
4
21. DO THE MEDICAL EXAMINATION (S) PASSED IPSO
FACTO ENTITLE ONE TO REGISTER IN THE
COUNTRY IN WHICH THEY WERE TAKEN OR A
SEPARATE EXAMINATION FOR REGISTRATION
HAS TO BE PASSED.
22. ARE YOU REGISTERED IN ANY FOREIGN COUNTRY?
IF SO, GIVE THE NAME OF THE BODY WITH WHICH
REGISTERED AND THE NUMBER AND DATE OF
REGISTRATION.
23. DETAILS OF PAYMENT OF FEES :
(a) PAID BY CASH/DEMAND DRAFT :
(b) AMOUNT RUPEES :
24. DETAILS OF DEMAND DRAFT:-
(a) NAME AND ADDRESS OF ISSUING BANK: _________________________________________
(b) DEMAND DRAFT NO. _________________DATED____________
(c) IF AMOUNT IS PAID BY CASH THEN CASH RECEIPT NO.
AND DATE AS ISSUED BY THE ACCOUNT SECTION OF MCI
25. EMAIL ADDRESS :
I solemnly affirm & declare that the entries made by me in the forms are correct and in the event of
any of the entries being found incorrect at any period of time, I shall be held responsible in any court of
Law.
DATE: SIGNATURE OF THE APPLICANT
PLACE: NAME OF THE APPLICANT
Form – MCI-06
5
DECLARATION
At the time of registration, each applicant shall be given a copy of the following declaration by the
Registrar concerned and the applicant shall read and agree to abide by the same.
1. I solemnly pledge myself to consecrate my life to service of humanity.
2. I will maintain the utmost respect for human life from the time of conception.
3. I will not permit considerations of religion, nationality, race, party politics or social standing to
intervene between my duty and my patient.
4. I will practice my profession with conscience and dignity.
5. The health of my patient will be my first consideration.
6. I will respect the secrets, which are confined in me.
7. I will maintain by all means in power, the honour and noble traditions of medical profession.
8. I will treat my colleagues with all respect and dignity.
9. I shall abide by the Code of medical ethics as enunciated in the Indian Medical Council (Professional
Conduct, Etiquette and Ethics) Regulations, 2002.
I make these promises solemnly, freely and upon my honour.
Signature……………………………
Name ……………………………….
Place …………………………….
Address ……………………………
Date ……………………………
Form – MCI-06
6
(AFFIDAVIT IN THE FOLLOWING FORMAT ON NON-JUDICIAL STAMP PAPER OF RS. 10/-
DULY SWORN IN AND ATTESTD BY FIRST CLASS MAGISTRATE FOR DELAY IN APPLYING
FOR REGISTRATION IN CASE DELAY IS MORE THAN ONE MONTH AFTER COMPLETION
OF INTERNSHIP TRAINING.)
I DR. ______________________________S/O SH. _________________________________ R/O
________________________________________________________ DO HEREBY SOLEMNLY AFFIRM AND DECLARE
AS UNDER: –
1. THAT I WAS A STUDENT OF MBBS OR CORRECT NOMENCLATURE OF QUALIFICATION IF OTHER THAN
MBBS AT________________________ MEDICAL COLLEGE FROM_____________________________________
TO _______________________.
2. THAT I HAVE COMPLETED MY COMPULSORY INTERNSHIP TRAINING
FROM____________________________ TO ___________________________.
3. THAT I HAVE COMPLETED MY COMPULSORY INTERNSHIP TRAINING FOR ONE YEAR/
__________________________________________________ (OR MORE AS THE CASE MAY BE) AT
______________________________ (DETAILS OF HOSPITAL WITH COMPLETE ADDRESS.)
4. THAT I COULD NOT GET MYSELF REGISTERED WITH M.C.I. DUE TO
________________________________________________________________________________________
________________________________________________________________ (SPECIFIC REASON FOR
THE DELAY MUST BE SPELT OUT BY THE CANDIDATE).
5. THAT I HAVE NOT DONE ANY UNETHICAL PRACTICE AFTER COMPLETION OF MY INTERNSHIP
TRAINING. HOWEVER, IF ANY COMPLAINT IS MADE AGAINST ME FOR UNETHICAL PRACTISE DURING
THIS PERIOD, I SHALL BE HELD RESPONSIBLE FOR THE SAME.
6. THAT ALL THE FACTS STATED ABOVE ARE TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE.
DEPONENT.
VERIFICATION:
VERIFIED AT ___________________ THIS_____________________________ DAY OF ____________________________
2008 THAT THE CONTENTS OF THIS AFFIDAVIT ARE TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE
AND BELIEF.
DEPONENT.
Form – MCI-06
7
CHECK LIST for submission of documents
The candidates are requested to ensure that the documents be enclosed as per the order in the
Checklist. All papers/documents should be numbered according to the checklist. Please arrange
the application in the following order & tick mark the relevant boxes:
1. Bank Draft for Rs.1,000/- 2,000/-
(Provisional) (Permanent)
2. Application form ……………………………………………………………………..
3. Declaration form …………………………………………..…………………………
5. Copies of MBBS/MD ‘Physician’ degree …………………………………………..…
6. Copies of Marks-sheet of ‘MBBS/M.D Physician’ Degree ……………………………
7. Copies of Marksheet of 12th Class (10+2) or equivalent examination. …………………
8. Copies of Pass Certificate of 12th Class (10+2) or equivalent examination. ..…………
(showing all the subjects & the name of the school).
9. Pass Certificate of 11th Class or equivalent examination. …………………………
10. Pass Certificate of 10th Class or equivalent examination.….……………………………
11. Eligibility Certificate issued to the Candidate by MCI for admission to Undergraduate
Medical Course abroad…………………………………………………………………………
12. Copies of Screening Test Result ……………………………………………………..
.
13. Photocopy of all the pages of all the passports showing visa the date of emigration
and immigration from and to Foreign country and India. …………………………..
14. Two photographs with front view & two signature slips.……………………..…………
15. Original Provisional Registration Certificate issued by MCI/any other State …………
Medical Council
16. Internship Completion Certificate. …………………………………………………..…
17. An affidavit for delay in applying for permanent registration-if the delay in applying
for registration is more than 30days after completion of internship. …………………
18. Letter from the Indian Embassy concerned that primary medical qualification as
possessed by the candidate is a recognized qualification for enrollment as medical
practitioner in the country in which the institution awarding the said qualification
is situated…………………………………………………………………………..
Signature ______________________________
Dated _________________________________
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Form – MCI-06
8
APPENDIX-I
INSTRUCTIONS
1. THE APPLICATION FORM SHOULD BE PROPERLY AND NEATLY FILLED IN CAPITAL LETTERS AND SHOULD
BE DULY SIGNED BY THE CANDIDATE. THE PHOTOCOPIES OF THE DOCUMENTS WHEREVER REQUIRED
SHOULD BE SELF ATTESTED BY THE CANDIDATE AND ALSO BY A GAZETTED OFFICER. THE
APPLICATION SHOULD BE SUBMITTED ALONG WITH THE FOLLOWING DOCUMENTS: –
(a) FOUR (4) XEROX COPIES OF
(i) MBBS/MD MEDICAL DEGREE CERTIFICATE .
(ii) XII PASS/SR. SECONDARY/INTERMEDIATE/+2 MARKSHEET AND PASS CERTIFICATE.
(b) ONE XEROX COPY OF
(i) INDIAN PASSPORT.
(ii) X PASS/MATRICULATION CERTIFICATE.
(c) TWO XEROX COPIES OF SCREENING TEST RESULT
(d) INTERNSHIP COMPLETION CERTIFICATE BY THOSE WHO APPLY FOR PERMANENT REGISTRATION
(e) ORIGINAL PROVISIONAL REGISTRATION CERTIFICATE ISSUED BY STATE MEDICAL COUNCIL/
MEDICAL COUNCIL OF INDIA BY THOSE WHO ARE APPLYING FOR PERMANENT REGISTRATION.
(f) AN AFIDAVIT FOR DELAY IN APPLYING FOR REGISTRATION IF THE DELAY IN APPLYING FOR
REGISTRATION IS MORE THAN 30 DAYS AFTER COMPLETION OF INTERNSHIP.
(g) THREE RECENT PASSPORT SIZE PHOTOGRAPHS WITH FRONT VIEW – Please write name on the reverse of the
photograph)
(h) SIGNATURE ON TWO SELF ADHESIVE SLIPS PROVIDED WITH APPLICATION.
(i) ORIGINAL 10+2 MARKSHEET BY THE APPLICANTS IN CASE THEY HAVE QUALIFIED THEIR 10+2
EXAMINATION FROM THE EDUCATION BOARDS OF THE FOLLOWING STATES:
(i) JAMMU & KASHMIR (iv) HARYANA
(ii) PUNJAB (v) RAJASTHAN
(iii) ANDHRA PRADESH (vi) KARNATAKA
(THE ORIGINALS ARE REQUIRED SINCE RESPECTIVE BOARDS CONFIRM THE AUTHENTICITY OF THE
CERTIFICATES ONLY UPON SUBMISSION OF ORIGINAL DOCUMENTS)
2. VERIFICATION FEE BY DEMAND DRAFT AS DETAILED BELOW BY THE CANDIDATES WHO HAVE
QUALIFIED 10+2 EXAMINATIONS FROM THE EDUCATION BOARD OF THE FOLLOWING STATES AT THE
TIME OF PROVISIONAL REGISTRATION:
(a) JAMMU & KASHMIR – Rs.400/- in favour of CHAIRMAN J & K STATE BOARD OF SCHOOL EDUCATION,
payable at J&K BANK REHARI COLONY JAMMU OR LALMANDI SRINAGAR.
(b) PUNJAB –Rs.300/- in favour of SECRETARY, PUNJAB SCHOOL EDUCATION BOARD, Payable at
MOHALI/CHANDIGARH.
(c) ANDHRA PRADESH – Rs.100/- in favour of Secretary, B.I.E. , A.P. , Hyderabad.
(d) ORISSA – Rs. 20/- in Favour of “FINANCE OFFICER, CHSE, ORISSA, BHUBANESHWAR”, PAYABLE AT
BHUBANESHWAR
Form – MCI-06
9
(e) GOA – Rs.100/- in favour of SECRETARY, GOA BOARD OF SECONDARY & HIGHER SECONDARY
EDUCATION, ALTO-BETIM-GOA. PAYABLE AT GOA.
(f) MAHARASHTRA – Rs.200/- in favour of DIVISIONAL SECRETARY, M.S. BOARD OF SECONDARY &
HIGHER SECONDARY EDUCATION of respective DIVISIONAL BOARD.
(g) GUJARAT –Rs.25/- in favour of SECRETARY, GUJARAT SEC. & HIGHER SEC. EDUCATION BOARD,
Payable at GANDHINAGAR,GUJARAT.
(h) RAJASTHAN –Rs.100/- in favour of BOARD OF SECONDARY EDUCATION RAJASTHAN, AJMER .
PAYABLE AT AJMER.
(i) New Delhi –Rs.300/- in favour of COUNCIL FOR THE INDIAN SCHOOL CERTIFICATE EXAMINATIONS,,
Payable at NEW DELHI
(j) DHAKA BOARD, BANGLADESH – 25/- TK Per Document PAYABLE AT __________________
(k) JESSORE BOARD, BANGLADESH – 100/- TK Per Document PAYABLE AT __________________
(l) RAJSHAHI BOARD, BANGLADESH – 100/- TK Per Document PAYABLE AT __________________
(m) RAJSHAHI UNIVERSITY, BANGLADESH – US $10/- Per Document PAYABLE AT __________________
(n) MEGHALAYA BOARD OF SCHOOL EDUCATION – Rs.200/- PAYABLE AT TURA
(o) WESTBENGAL – Rs.100/- in favour of WEST BENGAL COUNCIL OF HIGHER SECONDARY EDUCATION
PAYABLE AT KOLKATA
(p) BIHAR–Rs.50/- in favour of SECRETARY, BIHAR SCHOOL EXAMINATION BOARD, Payable at PATNA.
(q) TAMIL NADU – Rs.50/- in favour of Joint Director (Hr. Sec.) DTE of Govt. Exam, payable at Chennai (From
Nationalized Bank.)
(r) JHARKHAND – Rs.100/- in favour of Jharkhand Academic Council, Payable at Ranchi
(s) CBSE BOARD AJMER –Rs.100/- in favour of SECRETARY CBSE, Ajmer Payable at Ajmer.
(t) CBSE BOARD CHENNAI –Rs.125/- in favour of SECRETARY CBSE, Chennai Payable at Chennai.
(u) CBSE DELHI – Rs.100/- in favour of SECRETARY CBSE , PAYABLE AT DELHI
(v) CBSE GUWAHATI – Rs.100/- in favour of SECRETARY CBSE, PAYABLE AT GUWAHATI.
(w) CBSE PANCHKULA – Rs. 100/- in favour of SECRETARY CBSE, PAYABLE AT PANCHKULA
(x) CBSE ALLAHABAD – Rs. 100/- in favour of SECRETARY CBSE, PAYABLE AT ALLAHABAD
Note: If Roll Number starts with “1” to Ajmer, “2” to Panchkula , “3” to Guwahati, “4” to Chennai, “5” to
Allahabad, “6” to Delhi in case of CBSE BOARD ,.
3. FEE & MODE OF PAYMENT – A fee of Rs. 1000/- (Rs. ONE THOUSAND ONLY) FOR PROVISIONAL
REGISTRATION AND Rs.2000/- (Rs. TWO THOUSAND) FOR PERMANENT REGISTRATION BY A BANK
DRAFT IN FAVOUR OF “THE SECRETARY, MEDICAL COUNCIL OF INDIA”, PAYABLE AT NEW DELHI. ON
REVERSE OF THE DRAFT, FOLLOWING DETAILS TO BE FILLED BY THE APPLICANT AND DULY SIGNED: –
a) NAME
b) FATHER’S NAME
c) PURPOSE FOR WHICH THE DRAFT SUBMITTED
d) TELEPHONE NO WITH CODE/MOBILE NO.
Form – MCI-06
10
e) IN CASE OF PAYMENT IS MADE IN CASH, IT WILL BE MADE ONLY TO AUTHORIZED OFFICER IN
ACCOUNT SECTION OF MCI AND RECEIPT OBTAINED IN DUPLICATE. ORIGINAL COPY OF RECEIPT
WILL BE ATTACHED WITH THE APPLICATION AND DETAILS OF SUCH PAYMENT FILLED BY THE
APPLICANT IN THE FORM. DUPLICATE COPY OF RECEIPT WILL BE RETAINED BY THE APPLICANT.
NO PAYMENT WILL BE MADE IN CASH TO ANY PERSON OF MCI AT THE COUNTER OR ANY WHERE
ELSE EXCEPT IN ACCOUNT SECTION.
4. APPLICATION MUST BE COMPLETE IN ALL RESPECTS. NO ALTERATION WILL BE ALLOWED TO BE MADE
IN THE APPLICATION FORM AFTER IT HAS BEEN SUBMITTED TO THE COUNCIL
5. IT IS FOR THE INFORMATION OF THE CANDIDATES THAT THE CERTIFICATES WOULD BE SENT BY
REGISTERED POST /SPEED POST
6. PUBLIC DEALING WILL BE BETWEEN 3.00 TO 5.00 P.M., MONDAY TO FRIDAY.
7. APPLICANT IS ADVISED TO RETAIN COPY OF HIS APPLICATION AND DRAFT FOR FUTURE REFERENCE
8. THE APPLICANT IS REQUIRED TO BRING/SUBMIT ALL THE ORIGINAL DOCUMENTS INCLUDING ALL THE
PASSPORTS AT THE TIME OF SUBMISSIOM OF APPLICATION
Form – MCI-06
11
MEDICAL COUNCIL OF INDIA
Pocket – 14, Sector – 8, Phase-I, Dwarka, New Delhi – 110 077
Phone : 011-25367033,25367035, 25367036,
Email : mci@bol.net.in, Website : http://www.mciindia.org
——————————————————–
(to be filled by the candidate)
Received Application from Ms/ Mr.…………………………………………………………………
D/o / S/o Sh…………………………………………………………… alongwith Bank Draft/DD
No…………………………… dated..………………………….. for Rs……………………….
Drawn on Bank……………………………………………………………………………………….
for issuance of Provisional/ Permanent Registration Certificate for Indian Nationals having
qualified from the foreign medical institutions, for consideration.
Signature of Receiving Official
with date
ACKNOWLEDGEMENT
OFFICIAL
SEAL

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