Form of Application for Registration of Dentist under Section 34 of the Dentists Act, 1948 (XVI of 1948)
All Fields Marked '*' Are Mandatory.
Application Type
Personal Details
Name *

Father’s Name *

Spouse Name
Gender * Place of birth *

Date of Birth *

Date Of Birth In Words
Nationality (Kindly give information in details) *
Whether Citizen of India by domicile/birth *  
Voter Card No.


Please Do not Enter Adhar No.
Present Address
Address *

State *
Other *

District *
Other *

Pin Code *

Permanent Address
Tick Here if Permanent Address is same as Present address
Address *

State *
Other *

District *
Other *

Pin Code *

Contact Details
Email ID *

Phone Number With STD Code
Mobile Number *

Education Details
Description of qualification of which registration is desire *

Name of the University *

Institution through which appeared *


Whether final B.D.S. Degree has been received or not *
Date of attaining the qualification * (dd/MM/yyyy)

Retention
Retention For *
Fee for one year retention is ₹200/- and for five year retention is ₹1000/-
Do You want to collect Certificate by Online or by Post *
File Upload
#File Size should be less than 200KB, Photo and Signature should be in jpg Format,Other Document should be in jpg or jpeg or pdf.
Photo *

Signature *

High School Certificate/Mark Sheet *
Showing date of birth


Higher Secondary Certificate/Mark Sheet *

Mark Sheet of B.D.S. *
Upload single document for all marksheets


Paid rotatory Internship completion certificate *

Attempt certificate *

B.D.S. Degree
In case Degree is not granted by the University till today, then submit Provisional Degree Certificate

Domicile Certificate of Madhya Pradesh *

Character Certificate issued by the Dental College/Institute *

Declaration Form *
(To follow the code of ethics regulation – 1976)


College recognition certificate from D.C.I./Ministry of Health & Family Welfare, Govt. of India/Copy of Gazette Notification. *

Affidavit *
On Rs. 50/- Stamp paper (Non Judicial) duly Notarised


Photo ID & address proof *
PAN Card,Aadhar Card,Voter ID,Driving License,Passport.(Any two)


                          
 

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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