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TCMC Renewal Form

The document is an application for renewal of registration submitted by Dr. Veena P Reghunathan to the Travancore-Cochin Medical Council. It contains her personal details like name, address, registration number, qualifications, date of completion of internship. It also mentions remitting the renewal fee of Rs. 500 along with the declaration signed by her stating that she is still practicing and has not ceased to practice. It needs to be submitted along with original registration certificate, 3 passport size photos with one affixed and attested, self-addressed envelope and life certificate signed by a gazetted officer.

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R Ratheesh
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1K views4 pages

TCMC Renewal Form

The document is an application for renewal of registration submitted by Dr. Veena P Reghunathan to the Travancore-Cochin Medical Council. It contains her personal details like name, address, registration number, qualifications, date of completion of internship. It also mentions remitting the renewal fee of Rs. 500 along with the declaration signed by her stating that she is still practicing and has not ceased to practice. It needs to be submitted along with original registration certificate, 3 passport size photos with one affixed and attested, self-addressed envelope and life certificate signed by a gazetted officer.

Uploaded by

R Ratheesh
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOC, PDF, TXT or read online on Scribd
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TRAVANCORE-COCHIN MEDICAL COUNCIL

FOR INDIAN SYSTEMS OF MEDICINE


Combined council building, Red cross road, Thiruvananthapuram, Kerala - 695033
APPLICATION FOR RENEWAL OF REGISTRATION
1. Name (in Block Letters)

Dr. Veena P Reghunathan

2. Permanent Address

Abhiram, Olassery P.O.,


Kodumbu (Via), Palakkad - 678551
No

3. If there is change in address


Give the new address
4. Phone Numbers & e-mail ID

9446285770, veenapreghunath@gmail.com.

5. Fathers Name

Reghunathan

6. Date of Birth (in figures)

20/02/1978

( in words)

Twenty February One nine seven eight.

7. Registration Number and date of Registration : 7631, 16-07-2002


8. Qualification

B.A.M.S

9. Name of the College

Sri Jayendra Saraswathy Ayurveda Medical


College, Chennai
10. Name of the University
Sri Chandrasekharendrasaraswathy Viswamaha
Vidyalaya, Enathur, Kancheepuram,Chennai.
11. Date of completion of internship 16-05-2002.
12. Details of CME credit points
13. Details of fee remitted:

Amount Rs. 600/Chelan Receipt No. & Date..


DD No. & Date

Place: Thiruvananthapuram,
Date: 17/03/2014.

Signature

Declaration

I, Dr. . do hereby
declare that the details given above are true to the best of my knowledge and belief.

Place

Signature

Date

Name
Instructions

1. Original Registration certificate should be surrendered along with the application.


Registration certificate issued for additional qualifications need not be furnished.
2. Three passport size colour photos (identical) of which one should be affixed on a
plain paper and attested by signing across the photo by a Gazetted Officer of the
Kerala state with name, designation, Office seal and date should be attached with
the application.
3. Renewal fee of Rs. 500/- (Rupees Five Hundred only) should be remitted towards
the cost of the new certificate. Late fee of Rs 100/- ( Rupees One hundred only)
per year. (Fee can be remitted by the special Chelan issued by the council at the
SBT Main Branch, Thiruvananthapuram or by D.D. from any scheduled Bank
payable at the State Bank of Travancore, Thiruvananthapuram, drawn in favor of
the Registrar, Travancore cochin Medical councils.
4. Self addressed cloth lined envelop (30 cms X 26 cms ) should be attached for
sending the new Certificate by Registered post.
____________________

DECLARATION
I, Dr.Veena P Reghunathan, D/oReghunathan.
PossessingB.A.M.S(qualification) and residing
atAbhiram, Olassery P.O.,.,Palakkad, Kerala State, Pin Code -678551.(permanent
address with Pin code) hereby declare that I have not ceased to practice as such and my
present Professional
addrDr.VeenReghunathan..

Place :

Signature with Name

Date

Reg. No:
Date of Regn:

LIFE CERTIFICATE

I .certify that
Dr..
Holding Travancore Cochin Medical Council Registration No..
Who has signed in front of me is alive on this day..of2013

Signature of the Applicant

Signature of the Gazetted Officer


Name:
Designation
Seal:

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