RAJASTHAN STATE DENTAL COUNCIL, JAIPUR

Govt. Dental College & Hospital, Subhash Nagar,

Jhotwara Road, Jaipur – 302016 , Ph. :0141-2283920

Webside :rsdcjpr.org, Email- rsdcjaipur@yahoo.com

REGISTRATION VERIFICATION FORM

TO BE FILL BY APPLICANT

Form No…………………………….

Name………………………………………………………………………………......................

Qualification………………………………………………………………………………………..

Documents Attachments (Original & Attested Copies ):-

D.O.B. Certificate (10

Marksheet) BDS Final Year Mark Sheet

Internship Completion Certificate Degree/Provisional Degree

Address Proof D.D. worth Rs.800/-(for on year)

Voter ID/DL/Bonafied/Passport & U.I.D.) 2400/-(for five year)

500/-(Provisional Reg. fee)

Affidavit (On 50/- rupees stamp Two extra passport sized photograhphs

paper duly attested By a Notary)

MDS Mark sheet, if applicable MDS Degree /Provisional Degree

Copy of Transfer order issued by DCI. New Delhi (in case of transfer of registration)

Signature of Applicant

FOR OFFICE USE ONLY

Date of Application Submission………….……………………. Registration No………………………………………….

Reg. Date…………………………………………Reg. Valid Upto……………………………Receipt No……………………

Forms & Original Documents Checked By :

1 …………………………………………………………….

.……………………………………………………………..

Signature…………………………………………………..

2…………………………………………………………

………………………………………………………….

Signature ….…………………………………………..

Checked By:

Yuvraj Saini,

Rajasthan State Dental Council, Jaipur

Verified By :

Dr. D.K. Gupta

Registrar,

Rajasthan State Dental Council, Jaipur

Applicant Signature

RAJASTHAN STATE DENTAL COUNCIL, JAIPUR

Govt. Dental College & Hospital,

Subhash Nagar, Jhotwara Road, Jaipur-302016

Form No. ………………………

1. First Name …………………… Middle Name ……………………Last Name…………………………

2. Gender ………………………………………………………………………………………………………………..

3. Date of Birth ………………….. (In Words) ………………………………………………………………..

4. Birth Place …………………………………………………………………………………………………………..

5. Nationality …………………………………………………………………………………………………………….

6. PAN Number ………………………………………………………………………………………………………..

7. Father’s Name ……………………………………………………………………………………………………..

8. Mother’s Name ……………………………………………………………………………………………………

9. Residential Address ……………………………………………………………………………………………..

………………………………………………………………………………………………………………………………………………………………….

10. Professional Address …………………………………………………………………………………………..

………………………………………………………………………………………………................................

11. Mobile Number ………………………………… E-mail Address …………………………………………

12. Telephone Number ……………………………………………………………………………………………….

13. Fax Number ………………………………………………………………………………………………………..

14. Qualification for Registration ………………………………………………………………………………

15. BDS Degree Passing Date ………………………………………………………………………………………

16. BDS Degree awarding Authority/University ………………………………………………………..

…………………………………………………………………………………………………………………………….

17. BDS Degree Registration Date …………………………………………………………………………….

18. PG Degree Passing Date ………………………………………………………………………………………

19. PG Degree awarding Authority/University ………………………………………………………….

………………………………………………………………………………………………………………………………………………………………….

20. PG Degree Registration Date ……………………………………………………………………………….

21. PG Speciality ……………………………………………………………………………………………………….

22. Domicile Status (India/Foreign) …………………………………………………………………………..

-5-

SCHEDULE

FORM OF DECLARATION

(Sec regulation 3)

(i) I solemnly pledge myself to devote my life to the cause of serving humanity

in the field of dental care;

(ii) I shall not use my dental knowledge contrary to the laws of humanity;

(iii) I shall not permit consideration of religion, nationality, race, caste and

creed, party politics or social standing to intervene in my duty towards my

patient and the profession;

(iv) I shall look after the dental health of my patient as my first consideration;

(v) I shall honour the secrets which are confided in me by my patients during

the professional services;

(vi) I shall always maintain the honour and noble traditions of the dental

profession;

(vii) I shall deem it an honour to cherish a proper pride in my colleagues and

shall not disparage them by My actions, deeds or words;

(viii) I shall abide by the various provisions of the Act and desist from using a

degree/diploma or an abbreviation indicating or implying a dental

qualification, which is not in accordance with the definition of ‘recognized

dental qualification’ as defined under clause (j)of section 2 of the Act;

(ix) I shall not indulge in any activity which might bring discredit to the dental

profession.

Dated the Signature

Place Name of Dentist

Registration No.

Address

Phone

Correction

“Action 44 of the Act” as printed at the end of Rule 8 (1) of these Regulations, is an

apparent misprint for “Section 41 of the Act”. The Govt. of India have since issued a

corrigendum to this effect vide their corrigendum No.V.12025/7/76-MPT, dated

31.01.77.

GAZETTE OF INDIA PART-II

RAJASTHAN STATE DENTAL COUNCIL, JAIPUR

APPLICATION FORM FOR REGISTRATION OF

DENTISTS IN PART A & B

(Under Section 34 of Dentist Act., 1948)

To,

The Registrar,

Rajasthan State Dental Council,

Jaipur

Sir,

I request you to enter/renew my name & address in Part-A/Part-B of the register of Dentists for the state

of Rajasthan Registration fee of Rs. ……………..is sent herewith by Demand Draft No. ………………….. Date

………………… payable to Rajasthan State Dental Council, Jaipur.

1. Name in full with surname (In block letters only) ……………………………………………...……………..

2. Father/Husband’s Name …………………………………………………………..……………..….…………

3. Place of Birth ………………………………………………. D.O.B………………………...…………..……

4. Nationality ………………………………………………………………….……………………..…………...

5. Whether Indian Citizen by birth …………………………………………………………………….................

6. Whether naturalized Indian citizen ………………………………………………………………….................

7. Whether Subject of a Foreign Govt. ………………………………………………………….……..................

8. Residential Address ……………………………………………………………………………………………

………………Pin Code …………… Mob. No…………………. E-mail ……………………………………

9. Professional Address ……………………………………………………………………………….................

10. The exact date of commencement of practice ………………………………………………………................

11. Number of Year in practice …………………………………………………………………………................

12. Employment if any :

13. Whether already registered in the register of any other state :

(a) If so, mention Registration number & Date along with council name :

(b) (1) Whether such registration is still current

(2) If not, the reason therefore

14. Qualifications:

(a) Description of qualification of which registration is desired.

……………………………………………………………………………………………….………………...…..

(b) Name of authority which conferred the qualification with address.

………………………………………………..……………………………………………………………..…..…

………………………….………………………………………………………………………………………...

15. Additional Qualification:

(a) ……………………..……………… (b) ………………………………………………………………..

I enclosed herewith in original the documents, as desired in enclosed instructions. The same may please

be returned to me when no longer required.

Date: - / /

Place: Jaipur (Signature)

SPECIMEN SIGNATURE

(Please give below a specimen of your signature as will be used by you on certificate)

Thumb (Specimen Signature) Thumb

Impression Impression

FOR OFFICE USE ONLY

Received Application Form from Dr. /Sh./Smt./Ms. …………………………………………………on

along with Demand Draft No…………………….Dated ………………..Amount……….………….....

for registration in Register of dentists in part A/B

Receipt No. ……………………….

Date ……………………………….

(Signature)

(INSTRUCTIONS)

1. All particulars given must be filled in by the applicant himself.

2. All particulars should be in neat legible hand.

3. Registration fees should be sent only by a Demand Draft payable to “THE REGISTRAR, RAJASTHAN

STATE DENTALCOUNCIL, JAIPUR”

4. Applicant should note that their names entered in the application form must exactly correspond with their names

in the University or other exam, as the case may be or if there is change of name, affidavit on non-judicial stamp

of Rs. 50/- attested by first class magistrate.

5. Following documents (Original & one set of attested photo copies) should be sent along with application form :

(i) Date of Birth Certificate (10

Mark sheet)

(ii) Provisional Degree or Permanent Degree, Internship Completion Certificate, BDS Final year mark sheet

and MDS Mark sheet and Degree.

(iii) Copy of transfer order issued by DCI, New Delhi (In case of transfer of registration)

(iv) Proof of Residential address (Voter ID/Driving License/Electricity Bill/Passport/Bonafied Certificate or

Domicile)

(v) PAN Card

(vi) An affidavit on non-judicial stamp of Rs. 50 duly attested by a notary, stating :-

 Permanent residential address & professional address,

 Nationality,

 Undertaking that the applicant is not yet registered in any other Dental Council of India,

 Undertaking that the applicant will not continue registration in any other Dental Council after

getting registered in Rajasthan State.

 The applicant will abide by the decision of the scrutiny committee of the Council.

6. Attach two extra passport sized latest photographs (not more than 06 month)