Form Mci 06 – Fill Out and Use This PDF

FORM – MCI-06(OCI)

MEDICAL COUNCIL OF INDIA

APPLICATION FORM FOR PERMANENT REGISTRATION FOR
INDIAN NATIONALS / OCI REGISTERED IN
AUSTRALIA, CANADA, NEW ZEALAND, UK & USA
	Affix attested
(Kindly read the instructions carefully as given in Appendix-I before	front view
filling the form, in CAPITAL LETTERS in blue/black ball point pen only)	Colour
	Photograph

1.Name of the Applicant as it appears in the latest Postgraduate certificate (Initials not allowed):

2.Father’s Name:

3.

Sex: Male

Female

4.

Date of Birth:

DD

MM

YYYY

5.

Place of Birth:

6.

Age (as on 31st Dec. of 1st year medical course):

Years

Months

Days

7.Are you a Citizen of India/Overseas Citizen of India(OCI):

(a) BY BIRTH

(b) BY DOMICILE

(c) OCI

IF (b) STATE THE DATE OF BECOMING INDIAN CITIZEN

DD

MM

YYYY

8.PERMANENT ADDRESS WITH PIN CODE:

9.PRESENT CORRESPONDENCE ADDRESS WITH PIN CODE:

(If the permanent address is same as the present address write “SAME” only)

PHONE/MOBILE NO.:

E-MAIL ID

10. CATEGORY (GENERAL OR RESERVE i.e. SC/ST/OBC)

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FORM – MCI-06(OCI)

11.

MEDICAL QUALIFICATION DETAILS:

MEDICAL DEGREE /

NAME & ADDRESS OF

DATE OF ADMISSION

DATE OF PASSING THE

DIPLOMA OBTAINED

THE MEDICAL COLLEGE

IN COURSE

COURSE

& UNIVERSITY

GRADUATION

POST GRADUATION

SUPER SPECIALITY

OTHER, IF ANY

12.

REGISTRATION DETAILS:

NAME OF MEDICAL COUNCIL WITH

REGISTRATION NO.

VALID FROM

VALID UPTO

COMPLETE ADDRESS, PHONE NO.,

E-MAIL ETC.

13.

GOOD STANDING CERTIFICATE DETAILS:

NAME OF MEDICAL

LICENSE/

DATE OF

DATE OF REGISTRATION

DATE OF

COUNCIL WITH

REGISTRATION

REGISTRATION

OF ADDITIONAL

ISSUE

COMPLETE ADDRESS,

NO.

OF BASIC

QUALIFICATION

PHONE NO.,

MEDICAL

(PG/SUPER SPECIALITY/

E-MAIL ETC.

QUALIFICATION

OTHER, IF ANY)

14.DETAILS OF PAYMENT OF FEES:

Fee Amount Rs.

D.D.

D.D. No.

Date of Issue of D.D Receipt

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.

DATE:	SIGNATURE OF THE APPLICANT
PLACE:	NAME OF THE APPLICANT

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FORM – MCI-06(OCI)

DECLARATION

At the time of registration, each applicant shall be given a copy of the following declaration by the Registrar concerned and the applicant shall read and agree to abide by the same.

1.I solemnly pledge myself to consecrate my life to service of humanity.

2.I will maintain the utmost respect for human life from the time of conception.

3.I will not permit considerations of religion, nationality, race, party politics or social standing to intervene between my duty and my patient.

4.I will practice my profession with conscience and dignity.

5.The health of my patient will be my first consideration.

6.I will respect the secrets, which are confined in me.

7.I will maintain by all means in power, the honour and noble traditions of medical profession.

8.I will treat my colleagues with all respect and dignity.

9.I shall abide by the Code of medical ethics as enunciated in the Indian Medical Council (Professional Conduct, Etiquette and Ethics) Regulations, 2002.

I make these promises solemnly, freely and upon my honour.

Signature……………………………

Name ……………………………….

Place …………………………….

Address …………………………

Date ……………………………..

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FORM – MCI-06(OCI)

FORMAT OF AFFIDAVIT (DULY NOTARIZED) TO BE SUBMITTED ON NON JUDICIAL STAMP PAPER OF RS. 10/- BY THE APPLICANT, SEEKING PERMANENT REGISTRATION AT THE MEDICAL COUNCIL OF INDIA, WHO HAVE SECURED BOTH GRADUATE AND POST GRADUATE QUALIFICATIONS, RECOGNIZED FOR PRACTICING MODERN MEDICINE FROM AUSTRALIA, CANADA, NEW ZEALAND, UNITED KINGDOM & UNITED STATES OF AMERICA.

I, Dr. ____________son/daughter of _______________ permanent resident of _______________ currently

residing at _____________________do hereby solemnly affirm and declare as under:

I.I have successfully secured graduate medical qualification namely ___________ from

_______________ (name of University / Institution) situated at ____________ (place) in

_____________ (Country) in year ___________.

II.I have successfully secured postgraduate medical qualification namely ______________ from

___________ University / Institution situated at ____________ (place) in _____________ (Country) in year ___________.

III.I say that I have secured undergraduate and postgraduate medical qualifications from

____________________ (Australia / Canada / New Zealand / United Kingdom / United States of America) and the qualifications obtained by me are recognized medical qualifications for medical practitioner in the country from where I have obtained these qualifications.

IV. I have been registered with the Medical Council of __________ (name of the Country) bearing

Registration No. __________________, registered in year ____________ and I have not been held

guilty of professional misconduct.

V.I have also secured Good Standing Certificate issued by the Medical Council of _______________

(name of Country) bearing no. ____________ dated ___________.

OR

I have requested the Medical Council of ______________ (name of Country) to get a Good

Standing Certificate in my favour. As per the Rules and Regulations of the Medical Council of

____________ (name of Country) the Good Standing Certificates are not issued directly to the

applicant. It is sent directly to the concerned Medical Council.

*{Strike of whichever is not applicable}

VI. I say that I am/was covered by Medical Malpractice Insurance bearing Policy No. ____________

from __________________ (Name and address of the Insurance Company). I am covered/not covered

by Medical Malpractice Insurance for my practice in India.

VII. I say that the degree certificates / documents submitted along with the application for my registration are true and correct copies of respective originals.

VIII. I say that I have not made any false declaration about my qualifications and none of the certificates/documents submitted by me is/are false or fake.

IX. I say that Medical Council of India shall be at liberty to cancel my registration and take all such measure permissible in law including but not limited to filing of a criminal case for offence of perjury if it comes to the knowledge or discovered on its own or on verification at any stage by Medical Council of India that the declaration/information made herein above is false or certificates / documents submitted along with the application is/are fake.

Deponent

Verified on this day ___________ at _________ that the contents of above affidavit is true and correct to my

knowledge and nothing material has been concealed therefrom.

Deponent

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FORM – MCI-06(OCI)

APPENDIX-I

INSTRUCTIONS

1.THE APPLICATION FORM SHOULD BE PROPERLY AND NEATLY FILLED IN CAPITAL LETTERS AND SHOULD BE DULY SIGNED BY THE CANDIDATE. THE PHOTOCOPIES OF THE DOCUMENTS WHEREVER REQUIRED SHOULD BE SELF ATTESTED BY THE CANDIDATE. THE APPLICATION SHOULD BE SUBMITTED ALONG WITH THE TWO XEROX COPIES OF THE FOLLOWING DOCUMENTS: -

a)PRIMARY MEDICAL QUALIFICATION DEGREE CERTIFICATE

b)ALL POSTGRADUATE MEDICAL DEGREE CERTIFICATE/S

c)REGISTRATION CERTIFICATE

d)GOOD STANDING CERTIFICATE

NOTE: THE ABOVE CITED DOCUMENTS SHOULD BE DULY AUTHENTICATED BY THE COMPETENT MEDICAL REGULATORY BODY OF THE CONCERNED COUNTRY & DULY ENDORSED BY INDIAN EMBASSY/HIGH COMMISSION IN THE CONCERNED COUNTRY.

e)TWO ATTESTED COPIES OF PASSPORT

f)AN AFFIDAVIT OF DECLARATION REGARDING DOCUMENTS PROVIDED AND CREDENTIALS (link)

g)THREE RECENT PASSPORT SIZE COLOUR PHOTOGRAPHS WITH FRONT VIEW (Please write name on the reverse of the photograph)

h)SIGNATURE ON TWO SELF ADHESIVE SLIPS.

2.FEE & MODE OF PAYMENT: A FEE OF RS. 20,000/- BY A BANK DRAFT ONLY IN FAVOUR OF “THE SECRETARY, MEDICAL COUNCIL OF INDIA” PAYABLE AT NEW DELHI. ON REVERSE OF THE DRAFT, FOLLWING DETAILS TO BE FILLED BY THE APPLICANT AND DUTY SIGNED:-

a)NAME

b)FATHER’S NAME

c)PURPOSE FOR WHICH THE DRAFT SUBMITTED

d)TELEPHONE NO. WITH CODE/MOBILE NO.

3.APPLICATION MUST BE COMPLETE IN ALL RESPECTS. NO ALTERATION WILL BE ALLOWED TO BE MADE IN THE APPLICATION FORM AFTER IT HAS BEEN SUBMITTED TO THE COUNCIL

4.APPLICANT IS ADVISED TO RETAIN COPY OF HIS APPLICATION AND DRAFT FOR FUTURE REFERENCE.

5.THE CERTIFICATE WOULD BE SENT BY REGISTERED POST / SPEED POST.

6.PUBLIC DEALING WILL BE BETWEEN 3.00 TO 5.00 P.M., ON WORKING DAY’S (MONDAY TO FRIDAY).

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FORM – MCI-06(OCI)

MEDICAL COUNCIL OF INDIA

Pocket - 14, Sector - 8, Phase-I, Dwarka, New Delhi - 110 077

Phone : 011-25367033,25367035, 25367036,

Email : mci@bol.net.in, Website : http://www.mciindia.org

ACKNOWLEDGEMENT

--------------------------------------------------------

(to be filled by the candidate)

Received Application from Ms/ Mr.……………………….…………………………………… D/o / S/o

Sh……………………………………………………………...........................alongwith Bank Draft/DD

No…………………………… dated..………………………….. for Rs………………………. Drawn on

Bank………………………………………………………………………………………. for issuance of

Permanent Registration Certificate to Indian Nationals / OCI, registered in UK, USA, NEW ZEALAND, AUSTRALIA, CANADA, for consideration.

OFFICIAL	Signature of Receiving Official
SEAL	with date

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