Online Application Entry

Text

Inward No :

Provisional No :

Provisional Date :

Registration No :

Registration Date :

Date of Birth :

are mandatory fields

Personal Details :

First Name

Middle Name

Last Name

Gender

Nationality

Date Of Birth

Blood Group

Place Of Birth

Adhar No:

Change of Name :

First Name

Middle Name

Last Name

Contact Details :

Note :

Please change address, if your address is changed or not showing complete address.
Your documents will be posted on your Permanent Address.

Permanent Address

Don't include district,taluka/city and pin no in address.

Address

Pincode

Taluka/City

District

Telephone no

Mobile no

Professional Address

Don't include district,taluka/city and pin no in address.

Address

Pincode

Taluka/City

District

Telephone no

Email id

Qualification Details :

Qualification

PRN No

Exam Month

Exam Year

1st year admission date

University

College

Additional Qualification Details :

Qualification

Subject

Exam Month

Exam Year

University

College / Institute

OMS Registration Details :

Inward No

Prov. No

Prov. Date

Reg No

Reg Date

Admission From

Admission To

University

Good Standing Details :

Reason

Maximum 250 characters allowed

1st year marksheet required :

Yes

2nd year marksheet required :

Yes

3rd year marksheet required :

Yes

Other State Registration Details :

Other State Registration No.

Other State Registration Date.

NCH/CCH Regd.No.

NCH/CCH Regd. Date

Whether the Registration is Renewable or Permanent

Name of hospital or institute with complete address for purpose of teaching or research or practice of medicine

Name of Person in institution or hospital who will be responsible for legal issues regarding patient care provided by doctor concerned

This is As Per NCH Letter No.2-1/2021-NCH(BERH3932 dtd 13-12-2021)

Application Fee Details :

Amount (Rs.) :

Upload Following Documents :

Note : All documents should be in .jpg or .jpeg format.

Here is a sample of an affidevit for Regd. Form on page No. 3
Here is a sample of an affidevit for 100/- Stamp Paper

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