F

Phone : 0866 - 2455280, 2455281

E-mail : apmedicalcouncil@gmail.com Affix recent
passport size
Website : www.apmconline.in photograph duly
attested by any
ANDHRA PRADESH MEDICAL COUNGIL Civil Surgeon /
2nd Floor, Dr. N.T.R. University of Health Sciences, Principalof any
VIJAYAWADA - 520 008, A.P. Medical College /
Superintendent of
Application for Renewal of Medical Registration any Hospital
See Section-15C of A.P. Medical Practitioners Registration
. To (Amendment) Act,2013
lne Hegrstrar,
ANDHRA PRADESH MEDICAL €QIAICII-
20008'
Sir,
l, undersigned Dr. registered with
A.P. Medical Council under Registration No. dated-l have complied
with the requirements of Section-15C of A.P. Medical Practitioners Registration Act, 1968 (Amendment
Act No. 1O of 2013) and the rules made thereunder. Necessary Fee is paid herewith in the shape of
Demand Draft drawn in favour of Andhra Pradesh Medical Gouncil and request that my Medical
Registration may be renewed and a Certificate be issued. The details are as under.

Name of the Doctor:

(with Surname in full and in block letters)

Father's Name : Mother's Name :

Blood Group : Date of Birth : Sex:

Qualification :

i) Are you practicing : YES / NO

ii) lf practicing, at which place and designation ?

Permanent Address :

Pin Code :

E-mail : Ph.: Cell :

Medical Qualifications for Name of the Medical College & Details of
which Registration was University where the Registration No.
oranted Deqree was obtained and Date

The originals and the attensted copies of the required documents are submitted herewith.
The qriginals may kindly be returned when no longer required.
The above facts are true to the best of my knowledge.
yours faithfully,

(P.r.o.) (Signature of the Doctor)

 -

1. D.D. for Rs. 4,000/- drawn in favour of "Andhra Pradesh Medical Council.,, V tl,AyAfJlFM"
Hyderabad from Andhra Bank only.
ln case of ratkal Additional Fee Rs. z,ooot- if submitted before 1-00 p.m.
2. Final Medical Registration Certificate issued by A.P. Medical Council in original and its copy
and certificates.of Registration of Additional eualifications, if any.

3. Proof of Date of Birth (ssc, passport or any relevant certificate).

4. One recent passport size photograph (spare).
5. Attendance certificate of C.M.E. programmes having not less than 30 credit hours during the
preceding five years.

6. Late fee Rs. 100/- per month after stipulated period wef 1st April 2016.

D.D. No. Date Rs.

Bank Name

Branch Name Branch Code

REGISTRAR

Note :

i) Every Registered Medical Practitioner should renew his Registration after expiry of the
period of five years from the date of his original registration

ii) Renewal of Registration shall be done on or before the date specified by the Council in this
regard.

iii) The Hegistered Medical Practitioner who fails to renew his registration within the stipulated
period, g?rl reoew his registration upto d further period of onL year on payment of late fee.
No application for grant of renewal of Fl6gistration will be accepted on or after the date
specified in this regard even on payment oi late fee.

iv) The name of the Registered Medical Practitioner will"be removed from the Register, if
he/she fails to renew his Registrition as specified above.

v) Fresh Qegistration will be granted in case of the rernoval of names of Registered Medical
Practiti6ners from the Medical Register as per the procedure laid down in Rules.

The.Apptication may be downloaded from our Website : www.apmconline.in