APPLICATION FORM FOR REGISTRATION OF DENTAL CLINICS / ESTABLISHMENTS (Enclose photocopies of all requisite documents) ****************************** 1. Name of the clinic : 2. Name of the Dentist : 3. State Dental Council Regn. No. : 4. Qualification : Year of passing B.D.S : Year of Passing M.D.S. : 5. Residential Address : 6. Clinical Address: : 7. Owned/Rented ( enclosed Rented Deed 8. Telephone Nos: a) Residential b) Clinic Space for Photograph if rented) : c) Mobile_____________ 9. Consultation Hours : 10. Description of Clinic : 11. Main Operatory : 12. Waiting room : 13. List of Equipments : 14. List of Instruments : 15. List of materials : 16. Auxiliary staff with name : 17. Pollution Certificate if applicable : 18. Registration Certificate of State Labour Department if applicable. DECLARATION The information given by me in this form and enclosures is true and correct to the best of my knowledge and I have not concealed or misrepresented any facts. In the event of anything found false I undertake that I shall be personally responsible for the consequences whatsoever. Signature of the Applicant
