FORM OF APPLICATION FOR PROVISIONAL REGISTRATION To, The Registrar, Council of Homocopathic System of Medicine, Gujarat State “Council House", Nr. M. P. Shah Cancer Hospital, Gate No.6, Civil Hospital, Asarwa, Anmedabad - 380016. Ph, : 22681377 . Sir, request you to give the provisional registration under Rule 4 of the Central Council of Homoeopathy Rules 1983, and to issue the necessary certificate. My Particulars are stated below : (Beginning with Surname and including father's / Husband's Full Name in block letters only Address. woman (Beginning with Surname ‘Maiden Name and Surname in the case of a mari in block letters) Nationality. Date of Birth Qualification or examination Passed. Name of Council / Board / University Institution from which appeared for the Examination and number at the Examination Date of Passing the Examination or of obtaining the qualification 2. I Forward herewith Attested Copies of : (A) 8.S.C. Examination Certificates or School Leaving Certificate / Birthdate Certificate3 Ihave been selected for : Practica trafhingattie {State name of approved institution) spine and | enclosed as evidence. 4. The registration fee of Rs. 1000/- (Rupees One thousand) is sent in Gash / by Money Order for Provisional registration certificate. 5. lam applying for registration for the first time and i was not registered as a homoeopathic me practitioner in India before the date of this application. 6. _ Ihave carefully read the instructions sent with this form and i certify that the particulars furnished above are true to the best of my knowledge and belief. Yours Faithfully, Date Place : (Signature) student of our institute and passed final Thereby recommend Shri er ll complete his / her compulsory internship training without any B.H.M.S. on brake. ‘Signature & Seal, head of the Institution 1... All particualrs shall be filled by the applicant only. 2. Allparticulars should be in neat leglbe hand writting. 3. The registration fee should be sent in person or by money order. ‘When the fee is sent by money order, the postal receipt should be atteched to the application. 4. For joining of re-internshij Student will be allowed for rej of internship on production of satisfactory clarification and request from the Institution. Council will issue permission letter for the extention of intership period, and then after he / she will be allowed for re-internship. cacoresticiieicennncsnssieeliceialenetei