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DMLTRT Board

This document contains an application form for registration under the DMLT/DMRT Council of Odisha. It requests information such as name, date of birth, contact details, course details including name of institution and dates of admission and completion, registration and examination details, and scanned documents including a photo, signature, pass certificate and internship completion certificate. The form is to be submitted online for new, renewal or duplicate registrations under the DMLT/DMRT Council.

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Ama Agana
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158 views3 pages

DMLTRT Board

This document contains an application form for registration under the DMLT/DMRT Council of Odisha. It requests information such as name, date of birth, contact details, course details including name of institution and dates of admission and completion, registration and examination details, and scanned documents including a photo, signature, pass certificate and internship completion certificate. The form is to be submitted online for new, renewal or duplicate registrations under the DMLT/DMRT Council.

Uploaded by

Ama Agana
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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|STATE COUNCIL OF DIPLOMA IN MLT & MRT, ODISHA


 
APPLICATION FOR REGISTRATION UNDER DMLT/DMRT COUNCIL,ODISHA
 
First keep ready the Scan copy of Documents mentioned against (a) (b) (c) or (d) in .jpg / .jpeg Formats and then fill up the details
information as mentioned below
* Minimum Requirements
(a) Require amount of Challan paid through SBI e-Pay / SBI Collect through Online Mode Only (No Bank Draft will be accepted) *
(b) Scan copy of passport size colour photograph (4.5cm x 5 cm pixel 150 less than 50 KB) and Scan copy of Signature (6 x 1.5 cm 250 pixel 20KB) *
(c) Scan copy of Pass out certificate of DMLT/DMRT and Internship Completion Cert with CLC / TSLC last attended (For New/Fresh Registration)*
(d) Scan Copy Existing Registration Certificate and Pass out certificate of DMLT/DMRT (For Renewal Registration/Duplicate Registrationss )*
 
Please Fill up the Following Information to apply for Fresh Registration / Renewal of Registration/ Duplicate
Registration under DMLT/DMRTCouncil, Odisha
 
Please select the type of Registration *
  New or Fresh Registration
(Fresh/Renewal/Duplicate etc)

Please select the Course you have passed out * Diploma in Medical Laboratory Technology

Please enter Aadhar Number   837414928861

Please select the Year of passing of the Course *   2022

Please select the Name of the Institution from which


  GET INSTITUTE OF MEDICAL TECHNOLOGY, CU
you have passed out *

If select others ,please enter the Institute Name  

Enter SBI e-Pay / SBI Collect Reference No (DUXX)*   DUK4125699

DUK4125699 (If there is no such refernce number,


Enter SBI Bank Reference No (IGXXX)*  
write same DUB number here)

Please enter the Amount Paid (INR) *   1000

Please enter the Date of Payment *   13/01/2023 (DD/MM/YYYY)

Enter your Full Name (As per 10th certificate) *   ABHIJIT LENKA

Enter your Father Name (As per 10th certificate)*   PRASANT KUMAR LENKA

Enter your Mother's Name   PADMINI LENKA

Date of Birth (As per 10th certificate) *   20/03/2002  (Select from the Calender)

Gender / Sex *   Male

Please enter your Address Details *


  AT-CHHATRABAZAR, BALABHADRAPUR, PO-
(At-Po-PS-Via-Dt-Pin) ARUNODAYA MARKET PS BADAMBADI DIST
Please enter your Contact Valid Mobile No *   6372888747

Please enter your valid e-mail ID *   [email protected]

Examination held in the Month, Year *


(like June 2018)   MAY 2022
(As mentioned in Pass Certificate or Regd. Cert)
Duration of the Course (From)/ Date of admision /
  28/09/2019 (DD/MM/YYYY)
Joining in the Training *
Duration of the Course (To)/ Date of Completion /
  22/07/2022 (DD/MM/YYYY)
Relieving from the Training *
Roll no issued by DMLT/DMRT Board
  191L00594
(For New / Fresh Registration)
Existing Registration Number given by Board
 
(For Renewal / Duplicate Regd. only )
Existing Registration Date
   (DD/MM/YYYY)
(For Renewal / Duplicate Regd. only )
Existing Registration Validity Till
   (DD/MM/YYYY)
(For Renewal / Duplicate Regd. only )

Name of the Examining Body / Board / University *   D.M.L.T./D.M.R.T. EXAMINATION BOARD, GOVT. OF
Date of declaration of the Result (As per certificate)   21/05/2022 (DD/MM/YYYY)

Choose File SIGN ABHIJIT.jpg


Upload your Signature *
 
(Scan Copy of Full SIgnature size 6 cm x 1.5 cm)

Choose File PASS ABHIJIT.jpg

Upload your photo *


 
(Scan Passport colour photo size 4.5 cm x 5 cm)

Choose File DMLT ABHIJIT.jpg

Upload Scan Copy of Passout Certificate *


 
(For New / Renewal / Duplicate Registration only)

Choose File Untitled-1.jpg

Upload Scan copy of Internship & CLC/TSLC *


(For New Registrations) or Existing Registratioon  
Certificate (For Renewal / Duplicate Registrations)

                   

 
Submit     Cancel   Click for Login

    

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