Application form for Provisional Registration
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 ID/ Driving License/ PAN 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)

University Enrollment No.
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 proper single scanned document for all marksheets(Upload size 500 KB)

NEET UG Roll Number *

Attempt certificate *

NEET Score Card *
Domicile Certificate of Madhya Pradesh / Any State Citizen of India *

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 wish to apply for Provisional Registration ad Intern Dentist. I request to enter my name, address & qualifications as stated below for doing compulsory Paid Rotatory Internship.

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