Form of Application for registration of Dental Mechanic/Dental Hygienist under section 36,37 & 38 of the Dentist Act, 1948 (XVI of 1943)
Fields marked with * are mandatory
Application Type
Do You want to collect Certificate by Online or by Post *
Personal Details
Application For *
Name *
Date of Birth *
     
Father’s Name *
Place of birth *
Nationality (Kindly give information in details) *
Gender *
Whether Citizen of India by domicile/birth *  
Voter Card No.
Please Do not Enter Adhar No.
Present Address
Address *
Pin Code *
State *

District *

Permanent Address
Tick Here if Permanent Address is same as Present address
Address *
Pin Code *
State *

District *

Contact Details
Email ID *
Phone Number With STD Code
Mobile Number *
Experience Details
Number of years in practice * Employment, if any
Education Details
Description of qualification of which registration is desire * Name of the University *

Date of attaining the qualification * (dd/MM/yyyy) Institution through which appeared *
File Upload
#File Size should be less than 150KB except Last pdf Document which size should be less than 1MB.
Photo *
Signature *
High School Certificate/Mark Sheet
Showing date of birth *
Higher Secondary Certificate/Mark Sheet *
Dental Mechanic/Dental Hygienist Certificate issued by the Recognized Dental College *

Domicile Certificate of Madhya Pradesh / Any State Citizen of India *

Character Certificate issued by the Dental College/Institute *

College recognition certificate from D.C.I. for those who have passed Dental Mechanic/Dental Hygienist Course from the College *

Affidavit
The applicant who have passed Dental Mechanic/Dental Hygienist Course from out of M.p. shall submit an affidavit on Rs. 50/- Stamp paper (Non Judicial) that I am not registered in any State Dental Council other than M'P' State Dental Council, if this statement is found false, M.P. State Dental Council is authorized to cancel my registration and may take necessary action as Per law.

All Mark Sheets of Dental Mechanic/Dental Hygienist Course issued by the Recognized Dental College *
Upload single PDF for all marksheets

 

I hereby declare that the details filled above are correct. I further declare that I shall maintain the dignity and ethical standard of the profession in my practice as a Dentist. I undertake that I shall intimate to the Registrar,If there is any change in my address or place of practice.

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