Madhya Pradesh Medical Council Bhopal

Direct Permanent Registration Form For Foreign Medical Qualification Holder (DPRF)

* Fields are mandatory
Personal Details
Applicant's Name *
Father's Name * Mother's Name *
Date Of Birth * Age (as on date)
Place of Birth * Gender *
Category *  Domicile of M.P. *
Nationality *
Mobile Number * Email-Id *
Aadhar No.    
Passport Details
Passport No. Date of issue
Place of Issue   Address as on Passport  
Date of leaving India for pursuing course   Date of returning to India after completion of course  
Did you ever change/loss the Passport – due to any reason *
Reason for change of passport * Previous Passport No *
Date of issue * Place of Issue *
Address on Previous Passport * FIR Number in respect of lost Passport *
Screening Test Particulars
Date of Passing * Roll No. *
Completion Internship  Particulars
Date of Completion of Internship *  
Institution of Training *
Name of Indian Embassy * Address of Indian Embassy *
Was any medical college/school in India attended before departure from India ? *
Name of the Medical College/School * Period of study undergone*
Examination passed University Name *
If the language of study in the country be other than English,please Mention *
Language  *  
if it was studied in india before departure Or was study  *  
Period of study * Examination Passed *
Do the medical examination(s) passed IPSO FACTO entitle one to register in the country in which they were taken ? *
ARE YOU REGISTERED IN ANY FOREIGN COUNTRY ? *
Registration Number * Date of Registration*
Name Of Registered Body * Address Of Registered Body *
Have you done any part of your Medical course in India, or any country/other than where you have obtained Medical Degree ? *
Duration * Name & Address *
Address
Current/Correspondence Address *
City * State *
District *
PinCode *
Permanent Address *
City * State *
District *
PinCode *
Photo Signature: *
Declaration *
I solemnly affirm & declare that the entries made by me in the forms are correct and in the event of any of the entries being found incorrect at any period of time, I shall be held responsible in any court of Law.