Phone: 6557?

&43, Fax : 040-24657639

E-mail: apmedicalcouncil@gmail.com
Website: www. apmconline. in
Application for Provisional Medical Registration with
Recent
ANDHRA PRADESH MEDICAL GOUNCIL Passport Size
To, Photograph Affixed
The Registrar, andAttested'by
ANDHRA PRADESH MEDICAL COUNGII Principal of
Medical College
* 2nd Floor, Dr. NTR UHS, Viiayawada - 520008.
'
concemed
a.h,
I have the honour to request that my nam6, address and qualifications as stated
belowmay be registered undertheAndhra Pradesh MedicalPractitioners Registration
(Amendment) Act, 1986 and that t may be fumished with a certificate of Registration
FULLNAII/IE (lncluding Sumam6] :
(Full Name ehould be written irreepective of
fhe entry in the degree or other oertificates)
Sumam-e should be wriften first & in full
FATI{ERS NAME
MOTHER's NAME
DATE OF BIRTH

BLOOD GROUP
-- .......-_ElAlLlD
PERIIAI.IENTADDRESS

FHONE (LL)

Medlcal Quallficatlon of which. Madical Cotlage and place where Month and Year of
REgletration ls required, each was obtalned obtaining the Qualification
Name of tho University .

The Originals and the attested copies of required papers are sent submitted herewith. The originals
may kindly be returned when no longer required.
The above facts are true to the best of my knowledge. Yours faithfully,

lUsualSignatura of the Candidate)

Requiremente for PROVTSTONAL UEDICAL REGISTRATION :
1. tr@f&lJ99&in'favourof tromANDHRABANKonly.
2. Provisional MBBS Certificate.of the unlversity alongwith copy.
3. SSC oopy or Proof of Date of Birth.
4. Forwarding letter of Principal/ Dean of the College.
5. ln case frOm other state candidates, latest N.O.C,, Reglstration Certmcate and Degree Certificate
ohould be enclosedi

D.D.No. ' ' Date: For Rs.

fOthsr requiremants for medical graduates from
other gtat€ and ofter countries may be enquired, RE1GISTRAR