Application Form for Duplicate Provisional Registration
Fields marked with * are mandatory
Personal Details
Applicant's  Name
*
Salutation * First Name * Middle Name Last Name/Surname *
Father's Name* Mother's Name *
DOB (DD/MM/YYYY)*
  Age (As on date of  23/09/2018)
Nationality * Domicile*
Category * Gender *
Aadhaar Number*
Ex:  4567-7894-4561
Academic Details
Medical Qualification * Schedule
Month & Year Of Exam * MM Year
University *
College Name *
Provisional Reg. No. * Date (DD/MM/YYYY)*
Council Name *
     
Address
Current Address * State*
District*
PinCode *
Permanent Address(Same as Current Address)
Permanent Address* State*
District*
PinCode*
Mobile Number* Email-Id*
Photo & Signature: *
Declaration*
I here by declare that the particulars furnished above are true ,complete and correct to the best of my knowledge and belief . If any information is found false or incorrect or I am found ineligible , action may be taken against me and I may be disqualified/dismissed