15-10-2012

TRAVANCORE-COCHIN MEDICAL COUNCILS
Red Cross Road, Thiruvananthapuram-35
Application for Class ‘B’ Registration for self educated/Non-institutionally
qualified Naturopathy practitioners
Passport size
photograph
attested by the
forwarding
authority
1. Name :
2. Name of father/husband :
3. Permanent Address :
4. Present address :
5. Age and date of birth as on 17-8-2011 :
(to be supported by documentary evidence)
6. (1) Academic Qualification :
(10 th or its equivalent)
(a) Name of examination : SSLC/CBSC/ICSE/ISC/Others
(b) Board :
(c) Roll No. and year of passing :
(d)
Subjects:
(1) (2)
(3) (4)
(5) (6)
(2) Any other qualification(s) :
7. Details of professional experience :
8. Duration of practice of Naturopathy : [Year(s)]
9. Status of premises (rented/own) :
10. If owned/rented, details there of :
(supporting documents be attached)
11. Whether employed in Hospital or Clinic : [Yes/No]

(2)
12. If yes, give name and full address :
(a)
Details of work experience:
Sl.
No.
Name and full address
of the hospital/clinic
Period Designation Facilities
From To
Available
Salary/income
From practice

(3)
(b)
Details of the patients treated from 1-8-2001 onwards:
Year No. of patients Chronic
O.P. I.P. cases
2001
Acute cases
Success
percentage
Remarks
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012

(4)
13. Whether convicted by a Criminal :
Court or involved in a criminal case.
If so, details be given
(Documentary evidence must be
Produced)
14. Details of fee remitted :
D.D. No. :
Bank
favour of Payable at Rs. ……………… in (words)
15. Details of Experience Certificate obtained :
From concerned DMO (ISM) with
comments/Recommendations (certificate
must be obtained in the prescribed format)
Declaration:
I hereby declare that all the above information is correct to the best of my knowledge and
belief. In case any of the information is subsequently found to be incorrect, I accept that my
application will be rejected and that action as warranted under law may be taken against me.
Place :
Date :
Signature of the Practitioner
Note: 1.
Please enclose a write up on your practice – special skills, achievements, failures,
etc. in about 3 pages.
2. Please enclose copies of all relevant certificates duly attested by a Gazetted Officer
of the Kerala State to prove age, qualification, ownership of premises etc. and for
item No. 14, a Certificate obtained from a Police Officer not below the rank of S.I.
having jurisdiction over the place or places wherein the applicant resides. Originals
must be produced as and when required to do so.
3. Application fee once remitted shall not be refunded.

EXPERIENCE CERTIFICATE
Certified that Shri/Smt./Miss/ ………………………………………………………. S/o / D/o / W/o
…………………………………………….. resident of ……………………………………………..
Practicing Naturopathy at …………………………………………………………………………….
(address of Clinic/Hospital) during the period from ………………… to …………………. (enter
years).
Place :
Date :
Signature
(Name and address of the recommending authority)
(Rubber stamp)
(Comments/recommendation of Medical Officer of the District)