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