Beruflich Dokumente
Kultur Dokumente
MEDSS-CWT-2014
Recruitment of Technical & Paramedical Staff (Class III)
MEDSS-CWT 2014
AT
E
DIC A L E D UC A
TI
O
SE
RE
ARCH
DIRECTOR
ME
&
MEDSS-CWT 2014
Competitive Written Examination
IMPORTANT INFORMATION AT A GLANCE
1. Information Brochure, Online application form & other information
available on website.
www.dmerexam.com
2. Admit card will be available on website
3. Date of Examination
4. Centre of Examination
5. Schedule of Examination
a) Entry in Examination Hall
b) Distribution of answer sheets
c) Distribution of question booklets.
d) Examination Commences
e) Latest Entry permitted in Examination Hall
f) Examination concludes
6. Declaration of Final Result
7. Issue of Mark Sheet where the application form is submitted
PREAMBLE
The Government of Maharashtra has authorized the Director of
Medical
Education
&
Research
to
conduct
Medical
Education
(MEDSS-
CWT 2014) to fill up vacant class-III posts from technical cadre under
this Directorate. The Director of Medical Education & Research,
Mumbai is permitted to conduct MEDSS-CWT 2014 examination
by Government of Maharashtra vide letter No.Exam-0614/CR131/14/vaiseva-4, dated 27.06.2014.
Table of Contents
Sr. No.
Title
Page No.
Introduction
01
Definitions
01
Scheme Of Examination
02
03
05
Certificates
05
Tie-breakers
06
07
ANNEXURES
A
23
24
25
26
08-22
1. INTRODUCTION:
The Government of Maharashtra has decided to recruit competent and
efficient candidates with the help of competitive written examination. This
examination for the selection to fill vacant Class III Technical cadre posts in
various Government Institutions detailed in Annexure A in this brochure under
the jurisdiction of DMER shall be conducted by the Competent Authority
appointed by Government of Maharashtra. Separate State Merit List shall be
prepared for each type of post. The selection process shall be based on this
State Merit List and shall be carried out at a later date by the Competent
Authority. This procedure shall be governed by the rules, regulations and
directions specified by the Govt. of Maharashtra from time to time.
Honble High Court in W.P. No.70/2002, order dated 07.09.2006 has
directed the State Govt. as follows:- " Until the backlog of reserved posts for
handicapped persons as on 30th June 2006 is filled up by the State Govt. in
Toto, the State Govt. and its 27 departments are restrained from the
recruitment on any post on which a disabled/handicapped person may be
appointed ". As per above order, backlog of the Physically Handicapped posts
shall be filled first the on basis of State Merit List of MEDSS-CWT 2014
examination,
The Director of Medical Education & Research, Mumbai is permitted to
conduct MEDSS-CWT 2014 examination by Government of Maharashtra vide
letter No.Exam-0614/CR-131/14/vaiseva-4, dated 27.06.2014.
posts.
2. DEFINITIONS
2.1
"Online Application Form" means prescribed online application form
available on website www.dmerexam.com filled up by the candidate for
appearing for MEDSS-CWT 2014.
2.2
Appeal Committee means the Committee setup as per rule 8.1 under the
chairmanship of the Competent Authority.
It shall deal with the
representations submitted by the candidates/parents relating to grievances
of the candidates with regard to MEDSS-CWT 2014 examination and the
selection process
2.3
Competent Authority means the Authority appointed by Govt. of
Maharashtra to conduct MEDSS-CWT 2014, to declare the results and to
carry out further selection process. The Competent Authority will supervise
and control all activates related to the examination and act as a chairperson
of the Appeal Committee for representations submitted by the candidates.
The Competent Authority will issue necessary executive instructions for
implementation and provide relevant information to be published or
communicated.
2.4
Divisional Authority means the Deans/Officer(s) of specified Govt.
Medical Colleges who will be responsible to carryout the directions and
instructions of the Competent Authority.
2.5
2.6
2.7
"Nomadic Tribes (NT) means Nomadic Tribes as specified and laid down by
the Government of Maharashtra.
2.8
2.9
3.2
4.7
4.8
4.9
4.10
4.11
4.12
4.13
4.14
dates mentioned for Special Medical Board on the address mentioned in the
notification.
No separate individual intimation shall be sent about the Special Medical
Board. Those candidates who remain absent either for Examination or for
the Special Medical Board shall not be considered for selection to above said
posts reserved for Physically Handicapped candidates.
5. ONLINE APPLICATION INFORMATION BROCHURE:
5.1
Mode of Application: - Online application form will be available on
www.dmerexam.com. The cost of examination fee is Rs.500/-for open
category and Rs.400/-for reserved category candidates. This amount is not
refundable. Candidate has to pay exam fee in any SBI branch through
computer generated challan.
If candidate is eligible to apply for examination to a post either in Group A or
Group B, he may apply by filling two separate Application Forms. However,
the candidate is eligible to submit application form for only one Group-code
within Group A or Group B. A candidate can apply to separate post (Group
Code) within Group A & Group B.
5.2 An incomplete application form will not be accepted by online system.
Application form sent in any other mode will be rejected.
5.3
5.4
5.5
District
6.3 SSC i.e. 10th Standard or equivalent examination passing certificate and
SSC Statement of Marks of State of Maharashtra.
6.4 HSC i.e. 12th Standard or equivalent examination passing certificate and
HSC Statement of Marks of State of Maharashtra.
6.5 Medical fitness certificate (Annexure-E)
6.6 MS-CIT Passing Certifiacte
Chairman
Member
Member
Competent Authority
Joint Director
Dean, Grant Government
Medical College, Mumbai
ANNEXURE - A
Group A Posts ( -)
Sub-Code
Group-Code
Recruitment Rule
-
(X-Ray Technician)
..
B (C.T. Scan
Technician)
10 MCQ
Basic
Course -
15 MCQ Syllabus of
Qualifying
Course
HSC level
HSC level
X-ray
Technician
Course
HSC level
HSC level
X-ray
Technician
Course
MSW
MSW
MSW
B.Sc
B.Sc..
B.Sc.
Grade Pay
.-
9300&34800
is 4200
.-
9300&34800
is 4200
()/
3
A (Medical
Social Worker /
Medical Social
Superintend)
A (Laboratory
Technician)
A (Occupational
Therapist)
.-
.-
1) B.Sc.(Occupational Therapy)/
Bachelor of Occupational
Therapy (BOTh)
9300&34800
is 4300
B.Sc (OT) /
BOTh
9300&34800
is 4200
.B.Sc (OT)
/ BOTh
B.Sc (OT) /
BOTh
9300&34800
is 4300
Sub-Code
Group-Code
Recruitment Rule
A
(Physiotherapist)
(Orthotic Technician)
A (Prosthetist
Technician)
A (Audiometric
Technician)
10
A
(Physical Training
Instructor)
1) B.Sc.(Physiotherapy)
/Bachelor of Physiotherapy
(BPTh)
1) S.S.C.
AND
3 years Diploma course in
Orthotics conducted by All India
Institute of Physical Medicine &
Rehabilitation
OR
2) Bachelor in Prosthetics &
Orthotics (BPO)
OR
3) 2 years Certificate course in
Orthotics of a recognized
institute
AND
2 years infield experience after
acquiring such qualification.
1) S.S.C.
AND
3 years Diploma course in
Prosthetist conducted by All
India Institute of Physical
Medicine & Rehabilitation
OR
2) Bachelor in Prosthetics &
Orthotics (BPO)
OR
3) 2 years Certificate course in
Orthotics of a recognized
institute
AND
2 years infield experience after
acquiring such qualification.
1) Degree in Science with
Audiology or Speech Therapy
(BASLP)
OR
2) Posses Degree in Science
and Diploma in Audiology or
Speech Therapy from
recognized institute.
3) Preference will be given to
candidates possessing 1 year
experience in Audiology from
recognized Public or Private
institution.
1) B.P.Ed
OR
2) Degree of recognized
University & Diploma in Physical
Education from recognized
Training Institute (BPEd)
10 MCQ
Basic
Course -
15 MCQ Syllabus of
Qualifying
Course
B.Sc (PT) /
BPTh
B.Sc (PT)
/ BPTh
B.Sc (PT) /
BPTh
S.S.C
Certificate
course in
orthotics
Certificate
course in
orthotics
S.S.C
Certificate
course in
Prosthetic
s
Certificate
course in
Prosthetics
B.Sc.
Diploma in
Audiology
/ Speech
therapy
Diploma in
Audiology /
Speech
therapy
H.S.C
B.P.Ed/
D.P.Ed
B.P.Ed/
D.P.Ed
Grade Pay
.-
9300&34800
is 4300
.-
5200&20200
is 2800
.-
5200&20200
is 2800
.-
9300&34800
is 4200
.-
9300&34800
is 4300
Sub-Code
Group-Code
Recruitment Rule
11
(Dental Technician)
12
(Dietician )
1) B.Sc.(Home Science) of a
statutory University.
13
14
(Dialysis Technician)
A
(Assistant Librarian)
10 MCQ
Basic
Course -
15 MCQ Syllabus of
Qualifying
Course
1) B.Lib
OR
2) Degree in Arts/Commerce/
Science
AND
Diploma or certificate course of 6
months in Library Science of
Govt. recognized institute
3) Preference will be given to the
candidate having B.Sc. Degree
in Biology /Zoology
.-
SSC
D/C in
Dental
Mechanics
D/C in
Dental
Mechanics
BSc.
Degree in
Home
Science
BSc.
Degree in
Home
Science
BSc. Degree
in Home
Science
B.Sc.
B.Sc.
DMLT
9300&34800
is 4200
Certificate
Course in
Library
Science
Certificate
Course in
Library
Science
.-
Graduate
Grade Pay
5200&20200
is 2800
.-
9300&34800
is 4300
.-
5200&20200
is 2000
Group B Posts ( )
15
16
Sub-Code
Sr. Number
Recruitment Rule
(Pharmacist)
A (Laboratory
Assistant)
.SSC
Diploma in
Pharmacy
Diploma in
Pharmacy
SSC
SSC
DMLT
SSC
SSC
SSC
SSC
SSC
SSC
SSC
SSC
SSC
Graduate
Diploma
medical
Psychiatry
Social Work
Diploma
medical
Psychiatry
Social Work
18
19
-
(X-Ray Assistant)
(Darkroom Assistant)
A (Telephone
Operator)
20
()
(Medical Social
superident
(Psychiatry))
5200&20200
is 2800
.-
1) S.S.C./equivalent Examination
with Science Subject.
OR
BPMT (X-Ray Assistant)
17
Grade Pay
5200&20200
is 2000
.-
5200&20200
is 2000
.-
5200&20200
is 1900
.-
5200&20200
is 2000
.-
9300&34800
is 4300
21
Sub-Code
Sr. Number
Recruitment Rule
(Sanitary Inspector )
HSC
Grade Pay
Health
Sanitary
Inspector
Course
.-
HSC
.-
5200&20200
is 2400
.
2)
22
(Driver)
3)
24
3
4)
23
()
5200&20200
is 1900
A
(Tailor)
1) S.S.C./equivalent Examination
2) Diploma in Tailoring and
cutting from recognized institute
or any other Qualification
declared by Govt. to be
equivalent thereto..
3) Preference will be given to the
candidates who have
exceptional qualification or
experience or both.
A
(Dental Hygienist)
SSC
Tailoring
and Cutting
Course/
Diploma
Tailoring
and Cutting
Course/
Diploma
SSC
D/C in
Dental
Hygienist
D/C in
Dental
Hygienist
.-
5200&20200
is 1900
.-
5200&20200
is 2400
Sub-Code
Sr. Number
Recruitment Rule
(Artist)
25
26
A
(Library Assistant)
27
28
29
...
(E.C.G. Technician)
1) S.S.C./equivalent examination
AND
2) Certificate course in library
Science of recognized institute
1) B.Sc.with Physics, Chemistry
or Biology.
OR
BPMT (E.C.G.Technician)
2) Preference will be given to
candidates possessing 1 year
experience as a ECG technician
in Govt. recognized institute.
OR
Have completed training of ECG
technician from Govt. recognized
institute.
Degree/
Diploma in
Applied Arts
SSC
Certificate
Course in
Library
Science
Certificate
Course in
Library
Science
B.Sc
BSc..
BSc.
9300&34800
is 4200
Knowledge
of
maintaining
register &
Accounts
Knowledge
of house &
Linen
keeping
.-
Diploma/
Certificate
Course in
Electrical
Trade
Diploma/
Certificate
Course in
Electrical
Trade
.-
.-
B.Sc
Diploma in
Radiography
&
Radiotherap
y
A
(Electrician)
Technician)
5200&20200
is 2800
.-
5200&20200
is 1900
.-
1) S.S.C./equivalent Examination
AND
2) Diploma or Certificate in
Electrical Trades of any
recognized institution /NCTVT or
any other qualification declared
by Govt. to be equivalent.
3) Preference will be given to the
candidates who have three year
experience as Electrician.
A (Radiotherapist
.-
Degree/
Diploma in
Applied Arts
A (House & Linen
Keeper)
Grade Pay
SSC
1) S.S.C./ equivalent
Examination.
2) Have experience in maintaining
registers and accounts.
SSC
3) Should have previous
experience in house and linen
keeping for at least one year.
30
1)S.S.C./equivalent Examination
AND
2) Degree/Diploma in Applied Art
of a statutory University or
school of Arts recognized by
Govt.
AND
3) Posses experience of not less
than one year as Artist/
photographer/Artist-cumphotographer in an advertising
agency or in publicity department
of Govt. gained after acquiring
the mentioned qualification.
4) Preference will be given to the
candidates possessing
exceptional qualification/
experience or both.
SSC
B.Sc
5200&20200
is 1900
5200&20200
is 2400
9300&34800
is 4400
Sub-Code
Sr. Number
Recruitment Rule
Grade Pay
working in Radiotherapy
Department
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0
0
0
0
0
0
0
0
2
2
0
0
2
0
0
0
8
10
2
1
6
1
0
1
67
78
v-tekrh
fo-tk-(v)
Hk-t- (c)
Hk-t-(d)
Hk-t-(M)
fo-ek-iz-
b-ek- o
,dw.k
0
2
2
0
1
1
0
0
0
0
0
0
0
0
0
0
2
2
1
20
21
Hk-t- (c)
Hk-t-(d)
Hk-t-(M)
fo-ek-iz-
b-ek- o
,dw.k
lekarj vkj{k.k
efgyk
0
vjk[kho
5
,dw.k
5
fo-tk-(v)
AMQaarKaolaI sahayyak
v- lkekftd
dz vkj{k.k
1
2
0
3
3
v-tekrh
18 )
0
2
2
v-tkrh
1
2
lekarj vkj{k.k
ekth lSfud
1
vjk[kho
10
,dw.k
11
v-tkrh
v- lkekftd
dz vkj{k.k
vjk[kho
xaikrNa sahayyak
vjk[kho
17 )
1
1
2
0
1
1
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
1
7
8
fo-tk(v)
Hk-t(c)
Hk-t-(d)
Hk-t-(M)
fo-ek-iz-
b-ek- o
,dw.k
1
2
lekarj vkj{k.k
ekth lSfud
1
vjk[kho
5
,dw.k
6
v-tekrh
v- lkekftd
dz vkj{k.k
v-tkrh
dUrQvanaI caalak
vjk[kho
19 )
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
1
5
6
0
0
0
0
0
0
v-tekrh
fo-tk-(v)
Hk-t- (c)
Hk-t-(d)
Hk-t-(M)
fo-ek-iz-
b-ek- o
,dw.k
0
0
0
0
0
0
0
0
0
0
1
1
v-tekrh
fo-tk-(v)
Hk-t- (c)
Hk-t-(d)
Hk-t-(M)
fo-ek-iz-
b-ek- o
,dw.k
0
0
1
1
0
0
0
0
0
0
0
0
0
0
0
0
6
6
fo-tk-(v)
lekarj vkj{k.k
vjk[kho
5
,dw.k
5
vjk[kho
,dw.k
0
3
3
,dw.k
0
2
2
b-ek- o
0
2
2
fo-ek-iz-
p`klpga`st
Hk-t-(M)
1
2
Hk-t-(d)
1
4
5
lekarj vkj{k.k
Hk-t- (c)
v- lkekftd
dz vkj{k.k
v-tekrh
vaahna caalak
v-tkrh
22 )
0
0
v-tkrh
v- lkekftd
dz vkj{k.k
0
0
svacCta inairxak
vjk[kho
21 )
1
1
vjk[kho
lekarj vkj{k.k
vjk[kho
0
,dw.k
0
v-tkrh
v- lkekftd
dz vkj{k.k
vjk[kho
0
2
2
0
0
0
0
0
0
0
1
1
0
0
0
1
14
15
Hk-t- (c)
Hk-t-(d)
Hk-t-(M)
fo-ek-iz-
b-ek- o
,dw.k
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
1
2
3
fo-tk-(v)
Hk-t- (c)
Hk-t-(d)
Hk-t-(M)
fo-ek-iz-
b-ek- o
,dw.k
lekarj vkj{k.k
efgyk
1
vjk[kho
2
,dw.k
3
v-tekrh
dMt Aaraogyak
v- lkekftd
dz vkj{k.k
1
2
1
0
1
v-tkrh
24 )
vjk[kho
1
2
fo-tk-(v)
lekarj vkj{k.k
va'kdkyhu
0
vjk[kho
2
,dw.k
2
v-tekrh
v- lkekftd
dz vkj{k.k
v-tkrh
iSaMpI
vjk[kho
23 )
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
1
2
3
fo-tk(v)
Hk-t- (c)
Hk-t-(d)
Hk-t-(M)
fo-ek-iz-
b-ek- o
,dw.k
0
0
0
0
0
0
0
0
0
0
3
3
0
0
Hk-t- (c)
Hk-t-(d)
Hk-t-(M)
fo-ek-iz-
b-ek- o
,dw.k
lekarj vkj{k.k
vjk[kho
1
,dw.k
1
fo-tk-(v)
ga`Mqaalaya sahayyak
v- lkekftd
dz vkj{k.k
0
0
v-tekrh
26 )
2
2
v-tkrh
lekarj vkj{k.k
vjk[kho
1
,dw.k
1
v-tekrh
v- lkekftd
dz vkj{k.k
v-tkrh
klaakar
vjk[kho
vjk[kho
25
0
0
1
1
0
0
0
0
0
0
0
0
0
0
0
0
2
2
27 )
fo-tk-(v)
Hk-t- (c)
Hk-t-(d)
Hk-t-(M)
fo-ek-iz-
b-ek- o
,dw.k
0
0
0
0
1
1
8
8
fo-tk-(v)
Hk-t- (c)
Hk-t-(d)
Hk-t-(M)
fo-ek-iz-
b-ek- o
,dw.k
0
0
1
1
0
0
0
0
0
0
0
0
0
0
0
0
4
4
v-tekrh
fo-tk-(v)
Hk-t- (c)
Hk-t-(d)
Hk-t-(M)
fo-ek-iz-
b-ek- o
,dw.k
lekarj vkj{k.k
vjk[kho
0
,dw.k
0
v-tkrh
vaIjatM~I
1
1
0
0
0
0
0
0
0
0
0
0
0
0
0
0
1
1
Hk-t- (c)
Hk-t-(d)
Hk-t-(M)
fo-ek-iz-
b-ek- o
,dw.k
lekarj vkj{k.k
vjk[kho
2
,dw.k
2
fo-tk-(v)
roDIyaaoqaorapI tM~&
v- lkekftd
dz vkj{k.k
0
0
v-tekrh
30 )
0
0
v-tekrh
lekarj vkj{k.k
vjk[kho
3
,dw.k
3
v- lkekftd
dz vkj{k.k
0
0
v-tkrh
29 )
2
2
v-tkrh
v- lkekftd
dz vkj{k.k
2
2
gaRhinavas~pala
vjk[kho
vjk[kho
28
vjk[kho
v-tekrh
lekarj vkj{k.k
vjk[kho
3
,dw.k
3
v-tkrh
v- lkekftd
dz vkj{k.k
vjk[kho
[.saI.jaI.tM~&
1
1
0
0
0
0
0
0
0
0
0
0
0
0
1
1
4
4
ANNEXURE "B"
Guidelines for Online Application
ANNEXURE "C"
CONSTITUTIONAL RESERVATIONS
1) The candidates recognized by the State of Maharashtra as belonging to the following Backward
Classes, shall alone be eligible to claim admissions as against the seats reserved for such
backward class categories. These Backward Class categories are as follows:A Scheduled Castes and Scheduled Caste converts to Buddhism (SC)
13.0 percent
B Scheduled Tribes (ST)
7.0 Percent
C Vimukta Jati ( VJ/DT - v )
3.0 percent
D Nomadic Tribes ( NT & c )
2.5 percent
E Nomadic Tribes ( NT & d )
3.5 percent
F Nomadic Tribes ( NT & M )
2.0 percent
G Other Backward Category (OBC)
19.0 percent
H Special Backward Category (SBC)
2.0 percent
Total
52.0 percent
2) Candidates belonging to aforesaid Backward Class categories will be required to submit the Caste
Certificate and the Caste/Tribe Validity Certificate.
3) Caste certificate issuing authority: - Caste certificate stating that the caste is recognized under a
particular backward class category in Maharashtra state is issued by Sub-Divisional Magistrate /
Executive Magistrate /Metropolitan Magistrate in Maharashtra state.
4) The Caste/Tribe validity Certificate Issuing Authorities are as follows:a) For Candidates belonging to Scheduled Caste, Scheduled Caste converts to Buddhism,
Vimukta Jati (v), Nomadic Tribes c, d & M and Other Backward Class, Caste Validity
Certificate is issued by Divisional Caste Scrutiny Committee of respective Divisional
Social Welfare Office (Mumbai, Pune, Nashik, Aurangabad, Amravati, Nagpur and Latur).
b) For Candidates belonging to Scheduled Tribe the Tribe Validity Certificate is issued by
Commissioner/Jt. Commissioner, Tribe Scrutiny Committee of respective Region [Kokan
(Thane), Pune, Nashik, Aurangabad, Amravati, Nagpur, Nandurbar and Gadchiroli].
5) The candidates who have claimed the Constitutional Reservation in the original
Application Form must submit Caste Validity Certificate at the time of scrutiny failing
which the category claim, will not be granted.
6) NON-CREAMY LAYER
A candidate belonging to Creamy Layer amongst the categories (iii), (iv), (v), (vi) and (vii) must
note that the provision of reservation is NOT applicable to him/her. A candidate claiming benefit
of reservation under the categories (iii), (iv), (v), (vi) and (vii) above will be required to produce
Non-Creamy Layer Certificate in the name of candidate as specified in the Government
resolution No. lhchlh 10$2008$iz-dz-697$ekod] fnukad 13$01$2009- The certificate in
prescribed proforma issued on or after 24/7/2013 should be submitted at the time of scrutiny. The
Non-Creamy Layer Certificate is issued by Sub-Divisional Officer/Deputy Collector/Collector of
the district.
(Such a Non-Creamy Layer Certificate must be produced in any case at the time of
Scrutiny of Documents, Preference Form filling & Counselling failing which the category
claim will not be granted.)
---------------------------------------------------------------------------------------------------------------
ANNEXURE "D"
Physically Handicapped (PH) Reservation
PROFORMA OF CERTIFICATE FOR PHYSICALLY HANDICAPPED (PH) CANDIDATE
This is to certify that after clinical examination, it has been found that
Shri./Smt./Kumari. ..........................................................................who desires
to claim the benefit of seat reserved for Physically handicapped persons is an
individual with ........................................................... percent permanent /
temporary disability of Upper limb(s) / Lower Limb(s) /Vision / Hearing.
It is also certified that he/she fulfills the following criteria.
(1) Absence of any incapacitating and /or progressive systemic
disease/disorder/condition.
Yes/
Yes/
Yes/
It is further certified that he/she is medically fit to do the work required for the
post of ....................................................................................., inspite of his/her
physical disability being diagnosed as ..................................................................
Place :
Signature:
Date:
Name
:
Designation:
Official Seal :
.........................................................................................................................................................
ANNEXURE "E"
MEDICAL FITNESS
A candidate must be medically fit for selection for the post. The medical fitness must be
certified by a Registered Medical Practitioner in the prescribed proforma, as given below on a
Letterhead :
2.
3.
Yes/
4.
Yes/
5.
Yes/
1.
Yes/
6.
Yes/
Reasonable manual dexterity.
Though, following deviations have been revealed, in my opinion, these are not impediments
to do work as.......................................... (Name of the Post applied)
1. ...................................................................................................................
2. ...................................................................................................................
3. ...................................................................................................................
Address of the Registered Medical Practitioner
Signature:
Name:
Date :
Registration No.:
Seal of Registered Medical Practitioner