Candidate's Personal Appearance is Compulsory, is required to sign in a register in the council office".
UTTAR PRADESH MEDICAL COUNCIL
5, Sarvpalli, Mall Avenue Road, Lucknow
Office : 2235965, 2238846, Fax:-2236600, E-mail:upmedicalcouncil@upsmfac.org
Application Form for Registration with U.P. Medical Council
Provisional : Permanent : Additional : Duplicate :
Receipt # Date Neatly paste your latest
Candidate Signature in Upper Box colour photograph in
Reg. No. : this box duly
attested by principal
of training centre
Date of Birth :
Seal & Sign. of attesting authority
E-mail
Aadhaar No. Mob. No.
Name
Sur Name
Mother's Name
Father's Name
Address
District Pin
State Gender (M/F) : Year of Passing
Name of Medical College
Name of University :
Additional Qualification :
Month & Year of Joining : Month Year Month & Year of Passing Month Year
Registered with U.P. Medical Council (Y / N) State/U.T. of Registration (State Code)
Which Certificate you posses Provisional/Permanent (PROV/PERM) Registration No.
Rotatory training College details (To be filled by the applicant applying for PERMANENT REGISTRATION)
Training Hospital-1
Hospital name :
City :
Joining Date : Completed On
Day Month Year Day Month Year
Training Hospital-2 (If applicable)
Hospital name :
City :
Joining Date : Completed On
Day Month Year Day Month Year
Instructions for the printout of application Registration Form (Online Mode)
* Please get the colored print out in A4 Paper Size only Application Registration Form
* Print the application Registration Form in A4 Paper Size only
* Fill Separate forms for provisional / permanent/ Additional (MD/MS/etc) Registrations.
* Before / Additional Registration candidate should have permanent (MBBS) Registration from this council.
INSTRUCTIONS
* Aadhar copy is mandatory To be filled in the prescribed box .
1. Use black/blue ball pen for filling up the form .
2. Stick coloured passport size photograph do not staple or pin
3. Fill the form in English capital letter &
mention your email's and Aadhar no.
4. Do not use abbreviation as Dr, SMT, LATE, KM., MR., SHRI, etc.
5. Since it is a ICR form, please do not fold.
LIST OF ENCLOSURES FOR REGISTRATION
For doctors of the U.P. State Passout
(Should Be filled Online Mode bring Printout of form along with documents and submit it in council
within a period of one month)
1. Provisional certificate in original .
2. Date of birth certificate (marksheet/certificateof high school)
3. Internship completion certificate (form B ) In original .
4. Photo copy of MBBS marksheets
5. Affix photograph & signature separately in the box mentioned in the form and get it duly attested by
a) Principal of medical college .
or
b) C.M.S. of the hospital from where he/she has undergone internship .
For Doctors from other state passout
(Should Be filled Online Mode bring Printout of form along with documents and submit it in council
within a period of one month.
1. Photo copy of registration of parent council.
2. Photo copy of date of birth certificate (marksheet/certificateof high school.
3. Photocopy of internship completion certificate (form B )
4. Photo copy of MBBS Degree & marksheets.
5. NOC of parent council (ORIGINAL)
6. Affix photograph & signature separately in the box mentioned in the form and get it duly attested by
a) Principal of Medical College .
or
b) C.M.S. of the hospital from where he/she has undergone internship.
or
c) Seal bearing name and designation of CMO of the district mentioned in Aadhar Card.
or
d) SDM/ADM ( First class magistrate ) , Special Secretary and above official of the district mentioned in
Aadhar card.
For Duplicate Registration
1- Copy of F.I.R. 2- Publication in news paper (Original) 3-Affidavit on Rs. 100/- stamp paper .
4- Signature & Photograph should be attested by first class Magistrate of the district mentioned in Aadhar
Card .
For registration of Additional Qualification
1. Photo copy of MBBS registration by U.P.Medical Council .
2. Photo copy of additional qualification (P.G DEGREE) Certificate .
3. Affix photograph & signature in the box separately mentioned in the form and proforma of MCI, New Delhi
of recognized seats and get it duly attested by Dean/Principal of the college .
4. If he/she has done (P.G. from other state, then enclosed copy of additional qualification registration of
that state & NOC of parent council (Original).
5. List Of candidates who passed PG from MCI, New Delhi on recognized seat. (Batch wise)
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U.P. MEDICAL COUNCIL
5, SARVAPALLI, MALL AVENUE ROAD, LUCKNOW
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) Even under threat, I will not use my medical knowledge contrary to the laws of
Humanity.
3) I will maintain the utmost respect for human life from the time of conception.
4) I will not permit considerations of religion, nationality, race, party, politics or social
standing to intervene between my duty and my patient.
5) I will practise my profession with conscience and dignity.
6) The health of my patient will be my first consideration.
7) I will respect the secrets which are confined in me.
8) I will give to my teachers the respect and gratitude which is their due.
9) I will maintain by all means in my power, the honour and noble traditions of medical
profession.
10) I will treat my colleagues with all respect and dignity.
11) 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..........................................................
