Inspection Report of State Dental Council. APPLICATION FORM FOR REGISTRATION OF DENTAL LABORATORY (Enclose photocopies of all requisite documents) ****************************** 1. Name of the Lab : 2. Name of the Dental Surgeon/ Dental Mechanic : 3. State Dental Council Regn. No. as Dentist/ Dental Mechanic : 4. Qualification:-Year of passing B.D.S ( if applicable) : Year of Passing M.D. ( if applicable) : Year of passing of Dental Mechanic course in case of Mechanics : 5. Residential Address : 6. Address of the Lab : 7. Owned/Rented ( enclosed Rented Deed if rented) : 8. Telephone Nos: a). Residential _____________ b) Clinic ______________c) Mobile 9. Working Hours : 10. Description of Lab : 11. Main Operatory : 12. List of Equipments : 13. List of Instruments : 14. List of materials : 15. Auxiliary staff with name : 16. Pollution Certificate if applicable : 17. 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
