TAMIL NADU DENTAL COUNCIL

Ph : 044 - 23638476 Arihant Majestic Towers,

Email : tndental107@gmail.com 5-0-3, # 216, J. N. Salai
Web : www.tndentalcouncil.org Koyambedu, Chennai 600 107.

Renewal form for the year 2020 for life-time registered dentists

Name (Fill in Block letters)* :

Father’s Name (Fill in Block letters)* :

Mother’s Name (Fill in Block letters)* :

Gender : MALE / FEMALE

Date of Birth :

Birth Place :

PAN Number :

Domicile Status : INDIA / FOREIGN

Category : OC / FC / BC / MBC / SC / ST / PHD / Other -

Degree : BDS / MDS

TNDC Regn. No. :

Permanent Residential Address :

Full PINCODE & District name
(attach copy of address proof)
(Fill in Block letters)*

Mobile Number :
Landline Number :
E-mail ID (Fill in Block letters)* :
Aadhaar Number : / /

Signature :
Date :
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Documents to be submitted along with the Renewal form
1) Address proof in Tamil Nadu (Aadhaar Card, Voter id, Passport & Driving Licence)
2) A self-addressed envelope (size - 10” x 4”) affixed with Rs. 5/- Postal stamps.
3) All dentists are requested to renew on or before last renewal date (31.03.2020) to avoid
penalty.
(Note :- (a) No other documents to be attached