PROFORMA TO BE SUBMITTED BY HOMOEO PRACTITIONERS REGISTERED UNDER TCMC
This should be submitted by all Homoeo practitioners registered under Travancore Cochin Medical Councils
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Name *
Eg: SURESH KUMAR T S
Father's/Husband's Name
THANKAPPAN K M
Residential address *
Eg: KNRA 13, VATTAVILA VEEDU, PETTAH P.O.
District
State
PINCODE
Professional address
Eg: ROOM NO.28, PN HOSPITAL, NH BYPASS, KOLLAM 691575
General qualification *
Eg: PLUS TWO, BSc Degree in Zoology
Basic Medical qualification *
Date on which basic medical qualification obtained *
MM
/
DD
/
YYYY
Name of Institution/College from which basic medical qualification is obtained *
Eg: GOVT. HOMOEOPATHIC MEDICAL COLLEGE, THIRUVANANTHAPURAM
Name of University/Board from which basic medical qualification is obtained with State *
Eg: KERALA UNIVERSITY OF HEALTH SCIENCES, KERALA
State in which registered
Clear selection
Date of Registration in State register *
DD/MM/YYYY Format
MM
/
DD
/
YYYY
Registration number given in the state register *
Any other Additional medical qualification obtained
Clear selection
Specialization of Additional medical qualification
Date on Which additional medical qualification is obtained
MM
/
DD
/
YYYY
College/Institution from which Additional medical qualification is obtained
University from which additional medical qualification is obtained
Date and reasons of removal from the Central register if any
E-mail Address *
Mobile number *
Internship Period Start Date
MM
/
DD
/
YYYY
Internship Period End Date
MM
/
DD
/
YYYY
Adhaar Number
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