Application Form for Renewal of Identity Card - Chennai, Tamil Nadu India

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TAMIL NADU MEDICAL COUNCIL, CHENNAI.
APPLICATION FOR RENEWAL OF IDENTITY CARD
TO
Stamp Size
The Registrar
Photo
Tamil Nadu Medical
Council,Chennai- 600 106.
1.
Name of the Applicant
:
2.
Father's Name
:
3.
Qualification
:
4.
Regn. No.
:
5.
Date of Regn.
:
6.
Permanent Address for official record
& Identity Card Purpose :
Name of the Bank : .......................................
7.
Date of Birth
:
(Evidence should be attached)
.......................................
8.
Phone Number
:
Branch Name ................................................
(Land line with STD Code)
.......................................
9.
Mobile Number
:
D.D. No. .........................
Date ..........................
10. E-mail
:
Place :
Date :
SIGNATURE OF APPLICANT
INSTRUCTIONS
1.
All details to be filled in Capital and Bold letters only.
2.
Three recently taken Stamp size photographs should be sent, one affixed in the space provided for and others
enclosed to the Application Form.
3.
The prescribed fee for issuing identity card is Rs. 150/- by Demand Draft.
4.
Draft alone will be accepted and it should be drawn in favour of the Registrar, Tamil Nadu Medical Council,
Chennai.5.
Xerox copy of Medical Registration certificate.
6.
Xerox copy Photo identification (i.e. driving licence / voters I.D. card / Passport / or any other proof for
identification. 7.
Affix postage stamps for Rs. 22/- on the self addressed envelope which is attached herewith
Further enquiry:- Please contact Telephone No 2 6265678
8.
TAMIL NADU MEDICAL COUNCIL, CHENNAI.
APPLICATION FOR RENEWAL OF IDENTITY CARD
TO
Stamp Size
The Registrar
Photo
Tamil Nadu Medical
Council,Chennai- 600 106.
1.
Name of the Applicant
:
2.
Father's Name
:
3.
Qualification
:
4.
Regn. No.
:
5.
Date of Regn.
:
6.
Permanent Address for official record
& Identity Card Purpose :
Name of the Bank : .......................................
7.
Date of Birth
:
(Evidence should be attached)
.......................................
8.
Phone Number
:
Branch Name ................................................
(Land line with STD Code)
.......................................
9.
Mobile Number
:
D.D. No. .........................
Date ..........................
10. E-mail
:
Place :
Date :
SIGNATURE OF APPLICANT
INSTRUCTIONS
1.
All details to be filled in Capital and Bold letters only.
2.
Three recently taken Stamp size photographs should be sent, one affixed in the space provided for and others
enclosed to the Application Form.
3.
The prescribed fee for issuing identity card is Rs. 150/- by Demand Draft.
4.
Draft alone will be accepted and it should be drawn in favour of the Registrar, Tamil Nadu Medical Council,
Chennai.5.
Xerox copy of Medical Registration certificate.
6.
Xerox copy Photo identification (i.e. driving licence / voters I.D. card / Passport / or any other proof for
identification. 7.
Affix postage stamps for Rs. 22/- on the self addressed envelope which is attached herewith
Further enquiry:- Please contact Telephone No 2 6265678
8.

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