ANNEXURE IV - A

DELAY AFFIDAVIT PROFORMA FOR M.B.B.S STUDENTS

(PROVISIONAL & FINAL)

I, ________________________________ S/o, D/o, W/o, _____________________

aged: _______Yrs., H.No. ____________________________do hereby solemnly
affirm to state on oath as follows:

That I was a student of MBBS at ___________________________, completed

Internship on _______________.

That I have completed my Compulsory Rotatory Internship from ________________

to ___________at______________________________________.

That I could not get myself registered permanently with AP Medical Council due to
___________________________________________________.

That I have not done any un-ethical practice after completion of my Internship
training. 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 Dis-qualification for being registered under
the provisions of Sec 15(4) of AP Medical Practitioners Registration Act 1968
(As amended Act No. 28/1986).

I may be granted Final Registration duly condoning delay period of

_______Years_____ months ________days.

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

Place:
Date: DEPONENT

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