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1. Full Name :- llllllllllllll

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2. Registration No. & Schedule :- llllllllllllll
3. Registration Date :- llllllllllllll
4. Permanent Residential Address :- llllllllllllll
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5. Phone No. with STD Code :- lllll llllllll
6. Mobile No. :- llllllllllllll
7. Date of Birth :- llllllllllllll
8. Qualification :- llllllllllllll
9. University :- llllllllllllll
10. Year of passing degree :- llllllllllllll
11. Additional qualification (if any) :- llllllllllllll
12. University :- llllllllllllll
13. Passing Year :- llllllllllllll
14. Blood Group :- llllllllllllll
15. Signature of Practitioner :-
APPLICATION FORM FOR I-CARD
Note:-FeesofRs.200/-((RupeesTwoHundredonly)ifregisteredbefore31
st
December,2007.FeesofRs.300/-
(RupeesThreeHundredonly)ifregisteredin2008&thereafter.
Theaboveformdullyfilledinthelegiblehandwrittingshouldbesentontheaboveaddressalongwithacash
ofRs.200/300asapplicable.
SIGNATUREOFPRACTITIONER
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(Please fill in the following details with BLOCKLETTERS using a BLACKBALLPEN )
(STDCode)
Aarogya Bhavan, 4
th
Floor, Sent. Jorj Hospital Compound, P. Dimelo Road, Near CST, Mum-400 001.
Tel. :- (022) 2261 26 46 / 22 61 82 61
MAHARASHTRA COUNCIL OF INDIAN MEDICINE