UTTAR PRADESH MEDICAL COUNCIL

5, SarvpaIIi, MaII Avenue Road, Lucknow

Office : 2235965, 2238846, Fax:-2236600, E-maiI:upsmfIucknow@yahoo.co.in
App||cat|on Form for Reg|strat|on w|th U.P. Hed|ca| 6ounc||
Prov|s|ona| : Permanent : 0up||cate :
For Office use onIy :
Registration Number :.......................................................
Fee Receipt No. : .........................................................
Fee Deposit
Date :
Day Month Year
Fee Amount (Rs.) :
Date of Birth : Gender (M/F) :
First Name
Middle Name
Sur Name
Father's Name
Permanent Address
Distt. Pin
Name of Medical College
Name of University :
State Medical College Code University Code State Code
Month & Year of Joining : Month Year Month & Year of Passing Month Year
Note: FiII the detaiIs in this box if in case you are aIready registered with U.P. MedicaI CounciI or any other MedicaI CounciI
Registered with U.P. Medical Council/OtherCouncil (UPM/OTH)
Which Certificate you posses Provisional/Permanent (PROV/PERM)
Training HospitaI-2 (If appIicabIe)
Hospital name :
City :
Joining Date :
Day Month Year
Completed On
Day Month Year
Registration No.
State/U.T. of Registration (State Code)
Rotatory training CoIIege detaiIs (To be fiIIed by the appIicant appIying for PERMANENT REGISTRATION)
Training HospitaI-1
Hospital name :
City :
Joining Date :
Day Month Year
Completed On
Day Month Year
Add|t|ona| :
Additional Qualification :
Mob. No.
Card|dale W||| oe requ|red lo s|gr |r a reg|sler |r l|e courc|| oll|ce.
Candidate Signature in Upper Box
Seal & Sign. of attesting authority
Neatly paste your latest
colour photograph in
this box duly
attested by principal
of training centre
Serial No.
PERSONAL APPEARANCE IS COMPULSORY
(PIease read detaiIed instruction over Ieaf)
U.. MLDICAL CCUNCIL
S, SAkVAALLI, MALL AVLNUL kCAD, LUCkNCW
DLCLAkA1ICN
At the time oI registration, each applicant shall be given a copy oI the Iollowing declaration by
the Registrar concerned and the applicant shall read and agree to abide by the same:
1) I solemnly pledge myselI to consecrate my liIe to service oI humanity.
2) Even under threat, I will not use my medical knowledge contrary to the laws oI
Humanity.
3) I will maintainthe utmost respect Ior human liIe Irom the time oI conception.
4) I will not permit considerations oI religion, nationality, race, party, politics or social
standingto intervene between my duty and my patient.
5) I will practise my proIession with conscience and dignity.
6) The health oI my patient will be my Iirst consideration.
7) I will respect the secrets which are conIined 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 oI medical
proIession.
10) I will treat mycolleagues with all respect and dignity.
11) I shall abide by the code oI medical ethics as enunciated in the Indian Medical Council
(ProIessional Conduct, Etiquette and Ethics) Regulations 2002.
I make these promises solemnly, Ireely and upon my honour.
Signature....................................................
Name.........................................................
Place..........................................................
Address.....................................................
Date..........................................................