MEDICAL COUNCIL OF INDIA

Pocket - 14, Sector - 8, Phase- I , Dwarka, New Del hi - 110 077

Phone : 011-25367033, 25367035, 25367036,
!ai l : !ci "#ol $ net$ i n , %e#si te : htt&: ' ' www$!ci i n(i a$ or)
Form MCI-03
APPLICATION FORM FOR OBTAINING A
CERTIFICATE OF GOOD STANDING
(Please read the instructions carefully as given in Appendix-I before filling the form.)

1. NAME OF THE DOCTOR (AS GIVEN
IN THE INDIAN MEDICAL REGISTER)
2. FATHERS / HUSBANDS NAME (AS GIVEN
IN THE STATE MEDICAL REGISTER)
3. PRESENT ADDRESS WITH CONTACT DETAILS:
4. ADDRESS WITH CONTACT DETAILS IF
CERTIFICATE IS TO BE SENT ABROAD.
. !UALIFICATION
(NAME OF THE UNIVERSIT" WITH "EAR)
#. NAME OF THE COLLEGE WHICH APPLICANT
STUDIED AND !UALIFIED FROM:
$. STATE MEDICAL COUNCIL (S) WITH WHICH
REGISTERED REGISTRATION NO. (S) AND DATE (S).

%. PLACES AT WHICH HE HAD WOR&ED DURING
THE LAST FIVE "EARS WITH FULL DETAILS
(PLEASE USE SEPARATE SHEET IF SPACE
IS NOT SUFFICIENT).
'. DETAILS OF PAYMENT OF FEES :
(() PAID B" DEMAND DRAFT :
()) AMOUNT RUPEES :
1*. DETAILS OF DEMAND DRAFT:-
(() NAME + ADDRESS OF ISSUING BAN& :
()) DEMAND DRAFT NO. + DATE
SIGNATURE OF THE CANDIDATE
DATED ,,,,,,,,,,,
PLACE ,,,,,,,,,,,
RECOMMENDATION OF THE STATE MEDICAL COUNCIL: -

1
Form MCI-03
1. CERTIFIED THAT THE PARTICULARS GIVEN ABOVE ARE CORRECT TO THE BEST OF M"
&NOWLEDGE AND ACCORDING TO THE RECORD AVAILABLE WITH ME.

2. CERTIFIED THAT DOCTOR ,,,,,,,,,,,,,, S/O ,,,,,,,,,,,,,,,,,,, HOLDS CURRENT
REGISTRATION WITH THIS COUNCIL AND NO DISCIPLINAR" PROCEEDINGS HAD BEEN
TA&EN OR WERE IN PROGRESS AGAINST HIM ON THIS DATE B" THIS COUNCIL.

REGISTRAR.
STATE MEDICAL COUNCIL
DATED:
NOTE: THE CERTIFICATE OF GOOD STANDING ISSUED B" THE MEDICAL COUNCIL OF INDIA
WILL BE VALID UPTO SIX MONTHS FROM THE DATE OF ISSUE.
2
Form MCI-03
APPENDIX-I
INSTRUCTIONS TO CANDIDATE FOR FILLING THE APPLICATION FROM FOR OBTAINING A
CERTIFICATE OF GOOD STANDING.
1. THE APPLICATION FORM SHOULD BE PROPERL" AND NEATL" FILLED IN.
2. THE APPLICATION IS TO BE FORWARDED TO THIS OFFICE THROUGH THE
REGISTRAR OF THE STATE MEDICAL COUNCIL WITH WHOM THE PERSON
CONCERNED IS REGISTERED. IN CASE HE IS REGISTERED WITH MORE THAN ONE
STATE MEDICAL COUNCIL THEN HE SHOULD GIVE ALL THE REGISTRATION
NUMBERS. WITH DATES AND THE NAME OF THE STATE MEDICAL COUNCILS. BUT
FORWARD HIS APPLICATION THROUGH THE REGISTRAR OF ONE OF THE MEDICAL
COUNCILS.
3. PLEASE ENCLOSE AN ATTESTED COP" OF THE PERMANENT REGISTRATION
CERTIFICATE.
4. NON REFUNDABLE APPLICATION FEE OF RS. 2***/- (RUPEES TWO THOUSAND ONL")
B" A BAN& DRAFT IN FAVOUR OF /THE SECRETAR". MEDICAL COUNCIL OF INDIA.
NEW DELHI0. PA"ABLE AT NEW DELHI. ON REVERSE OF THE DRAFT. FOLLOWING
DETAILS TO BE FILLED B" THE APPLICANT AND DUL" SIGNED: -
(() N(12
()) F(34256 N(12
(7) P859:62 ;:5 <4=74 342 >5(;3 68)1=332>
(>) T2?294:@2 N: <=34 C:>2/M:)=?2 N:.
. IF THE CERTIFICATE HAS TO BE SENT ABROAD B" COURIER OR B" FAA TO THE
FOREIGN COUNCIL/COUNTR" THEN THE FEE WOULD BE $00 OR E!UIVALENT IN
INDIAN CURRENC".
#. IT IS FOR THE INFORMATION OF THE CANDIDTES THAT THE CERTIFICATES WOULD
BE SENT B" REGISTERED POST/ SPEED POST.
$. PUBLIC DEALING WILL BE BETWEEN 11.** A.M TO 1.** P.M.. MONDA" TO FRIDA".
%. APPLICANT IS ADVISED TO RETAIN COP" OF HIS APPLICATION AND DRAFT FOR
FUTURE REFERENCE
BBBBBBBBBBBBB
3
Form MCI-03
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MEDICAL COUNCIL OF INDIA
Pocket - 14, Sector - 8, Phase- I , Dwarka, New Del hi - 110 077
Phone : 011-25367033, 25367035, 25367036,
!ai l : !ci "#ol $ net$ i n , %e#si te : htt&: ' ' www$!ci i n(i a$ or)
Form MCI-03
--------------------------------------------------------
(to be filled by the candidate)
Received Application from Ms/Mr.
D/o / S/o Sh......... alongith !an" Draft/DD
#o dated.... for Rs.
Dran on !an".
for iss$ance of %ood Standing &ertificate for consideration.
Signat$re of Receiving 'fficial
ith date

ACKNOWLEDGEMENT ACKNOWLEDGEMENT
*++I,I-
. S-.