Inspection Report of State Dental Council APPLICATION FORM FOR REGISTRATION OF DENTAL X-RAY UNIT (Enclose photocopies of all requisite documents) ****************************** 1. Name of the X-ray Unit : 2. Name of the Dental Surgeon/ Radiologist/ X-ray Technician : 3. State Dental Council Regn. No. as Dentist : 4. Qualification:- Year of passing B.D.S (If applicable) : Year of Passing M.D.S. (If applicable) : Year of passing of radiology course : 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 X-ray Establishment : 11. Main Operatory : 12. Capacity of the X-ray Unit : 13. Waiting room : 14. List of Equipments : 15. List of Instruments : 16. List of materials : 17. Auxiliary staff with name : 18. Pollution Certificate if applicable : 19. 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. Signatute of Applicant
