TRAVANCORE-COCHIN COUNCIL OF INDIAN SYSTEMS OF MEDICINE
APPLICATION FOR GOOD STANDING CERTIFICATE
1. Name (in block letters) ::
2. Address ::
3. Phone numbers/e-mail ID ::
4. Registration No. and date ::
5. Qualifications registered:
6. Purpose for the certificate CCIE 400-101 ::
7. Whether new Registration certificate with ::
Security features has been obtained or not
8. Details of fee remitted:
No. and date of Chalan/DD ::
9. If required to send the certificate directly ::
from the Council by speed post SY0-301 exam or by fax
or by e-mail to abroad, give full address/details of fax number/e-mail ID
I, Dr. …………………………………………, do hereby declare that no disciplinary action has been taken or is pending against me by the Medical Council of India or by any State Medical Council.
I also declare that the details given above are true to the best of my knowledge and belief.
Date : Name & Signature of the applicant
1. Fee for Good Standing Certificate is Rs.2500/-. For sending the certificate directly by fax or speed post or by e-mail to abroad, the fee is Rs.5000/-.
2. Fee can be remitted by the special chalan issued by the Council at the SBT Main Branch, Thiruvananthapuram or by D.D. from any Scheduled Bank payable at the State Bank of Travancore, Thiruvananthapuram, drawn in favour of the Registrar, TravancoreCochin Medical Councils, Thiruvananthapuram.
3. Attested copies of the Registration Certificates (Both basic and additional qualifications) should be produced along with the application.