ANNEXURE IV - F

AFFIDAVIT PROFORMA FOR RE-REGISTRATION

(IN CASE OF DELAY BEYOND 7 YEARS ALONG WITH DECLARATION)

I, Dr. _______________________ S/o. D/o. W/o. __________________

Aged _________ years, Resident of __________________________ do
hereby solemnly affirm and declare on oath as follows:

That I was a student of MBBS from ________________ Medical

College.
I have completed my Internship in the month of ___________________.
I got myself Registered with AMC/HMC/APMC on ______________,
vide Registration No. ______________________.
I could not get my Registration renewed due to ___________________.
That I have not done any unethical practice after expiry of validity of my
Final Registration on _______________, the date on which my name
was removed from the Medical Register. However, if any complaint is
made against me, I will be held responsible for the same.
That I have not done any act amounting to disqualification for getting
the Re-Registration as per Section-15 of Andhra Pradesh Medical
Practitioners Registration Act, 1968 (Amended as Act No. 10/2013) and
I may be granted Re-Registration duly condoning the delay period
of ______ year _______ months ______ days.

The facts stated above are true and correct to the best of my knowledge
and belief.

Place: DEPONENT
Date:

[ON A NON-JUDICIAL STAMP PAPER TO BE ATTESTED BY A NOTARY PUBLIC]