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Renewal of Regn. Form

pdc renewal form

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simranjitkaurup
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453 views2 pages

Renewal of Regn. Form

pdc renewal form

Uploaded by

simranjitkaurup
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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FORM FOR RENEWAL OF REGISTRATION

(Under the Dentists Act 1948)


Recent
PUNJAB DENTAL COUNCIL, S.A.S.NAGAR P.P.Size
Medical Education Bhawan (3rd Floor), Sector-69, S.A.S.Nagar-160062 Photograph
Website: www.punjabdentalcouncil.com
Email: [email protected]
Telephone No.0172-5197531
(To be filled in by the candidate)
B.D.S. Regn. No_______________________
(already issued by this council)
1. Name of Doctor :___________________________________________________
(In Block Letters only)

2 Date of First Registration :___________________________________________________


3 Father’s Name :___________________________________________________
4 Mother’s Name :___________________________________________________
5 (i)Qualification (BDS) :___________________________________________________
Name of College & Univ. ___________________________________________________
(ii)Qualification (MDS) :___________________________________________________
Name of College & Univ. ___________________________________________________
6 B.D.S.Degree Regn. Date :___________________________________________________
7 Date of Birth :___________________________________________________
8. Birth Place :___________________________________________________
9 Nationality :___________________________________________________
10 PAN Number :___________________________________________________
11 Residential Address :___________________________________________________
___________________________________________________
12 Professional Address :___________________________________________________
___________________________________________________
13 Mobile No.& Tel. No. :___________________________________________________
14 E-mail Address :___________________________________________________
15 Date of Last Renewal :_____________________

Dated:___________________________ ________________________
Signature of the Applicant

Name in full…………….…………………………..

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Renewal upto 31.12.___________


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Page-2
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Instructions regarding Renewal of Registration:-
1. The Dentists can pay their renewal fee under “Renewal” Section by Login into their
account/profile on website of Punjab Dental Council i.e.www.punjabdentalcouncil.com :-
Step 1 - Go to website of Punjab Dental Council i.e.www.punjabdentalcouncil.com
Step 2 - login using username and password.
Step 3 - Go to Renewal section.
Step 4 - fill up required information and proceed to pay.
2. The applicant can also come personally for his/her renewal of registration, along with
Original Registration Certificate.
3. In case a Dentist cannot come personally, he / she can submit his / her Form for renewal,
with renewal fee, by post or through someone, with photocopy of Registration Certificate.
4. Renewal fee can be deposited in cash or Bank Draft favoring “Registrar Punjab Dental
Council” payable at Chandigarh @ 200 per year (plus late fee @ 500 per year if
registration is not renewed till 31st March) and 100 as Maintenance Fund.
5. The Dentists applying from foreign countries can also go for online renewal and can pay
renewal fee as mentioned above at Sr. No. 1.
6. Any change in his/her Permanent address should be intimated to the Registrar Punjab Dental
Council by sending separate request with this Form.
7. Timing for payment of fee: 9:00 A.M. to 01:00 P.M. and 2:00 P.M. to 3:00 P.M. on any
working day.
8. Entry of renewal of registration will be made only on Original Registration Certificate.
After renewal, original Registration will be issued after 3 Working Days

Self Declaration

I_________________________________S/O,D/O___________________________________
R/O _________________________________________________________________________,
do hereby solemnly affirm and declare as under:-

1 That I am registered with Punjab Dental Council, vide Registration No. _______________
since _____________.

2. That I could not get my registration renewed from the year ________.

3 I certify that I am not registered with any other State Dental Council in India.

4 I certify that I was not involved in any court case or any legal proceedings are pending
against me professionally or otherwise. Kindly renew my registration.

Signature of the Declarant


Dated: ____________

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