Rajasthan Para-Medical Council, Jaipur
Application Form – Registration Certificate
To,
Color Passport
The Registrar
Size photo
Rajasthan Para Medical Council
Attested by
Jaipur.
Gazetted officer
Sub : Application for Registration as Para Medical Professional
(Name of the course)……………………………………………………
1. Name of the Applicant (In BLOCK letters) :
2. Father's Name (in BLOCK letters) :
3. Mother's Name (in BLOCK letters) :
4. Gender :
5. Date of Birth in figures : / /
6. Communication/Permanent Address
Pincode :
7. Mobile Number :
8. E-mail ID :
9. Name of state according Bona-fide residence certificate :
10. Nationality :
11. Educational Qualification
[Link]. Name of The Name &Address of the Period Year of Percent age Name of University/Board under which
course Institute/Collage of study passing of marks the course was conducted
1
2
3
4
5
12. Experience :
S. NO. Name of Period of Total Name address of the Head of
Hospital/Institute/Collage work experience institute with phone/mob. No.
1
2
3
4
5
13. State the category to which the registration is applied
(See the instruction)
14. State the medium of instruction of training
15. Details of remittance of registration fee
(DD Number and Date/challan number and date/transaction number and ID if paid through online)
Signature of Applicant With Name
DECLARATION
I…………………………………………………………………(Name) hereby declare that the above statement are
true to the best of my knowledge and belief and the I am free from the disqualification mentioned
in the Rajasthan Para-medical Council Act, 2008, rules and regulations. I promise in the event of
being registered and in consideration thereof to be bound by and to conform in all respects to the
rules, regulation etc. framed by Council form time to time in force.
Place :
Date :
Signature of Applicant With Name
Instructions for Filling Registration Form
1. Applicant shall enclose a D.D. of Rs. 3000/- (for each Course) drawn in favor of Registrar,
Rajasthan Para Medical Council, Jaipur. Applicant registered with other State Councils will pay
4000/- as registration fee and applicant qualified from other countries will pay Rs. 10000/- as
registration fee.
2. Registration fee will not be refunded for any reason.
3. Three recent and identical passport size color photographs are to be used (all photos should be
same). One should be pasted on the space provided on the application form and that should be
attested by a gazette officer/Head of the Institution where the candidate is studying/has studied
for the qualifying examination/or Head of Institution where he is working. The other copies of
photograph (unattested) should be enclosed with the application and his/her name and date of
birth should be printed/written on its bottom.
4. The following documents should be enclosed with the duly filled application form in the
order below -
i. Demand-draft in favor of Registrar, Rajasthan Para Medical Council, Jaipur.
ii. Attested copy of the letter of the recognition of the institution/college/university (issuing
diploma/degree) from any state Government or Central Government for the purpose.
(Both side, if any)
iii. Self Attested copy of Secondary School Mark Sheet & Certificate to prove the date of
birth.(Both side)
iv. Self Attested copy of 10+2 (PCM/PCB) Mark Sheet & Certificate. (Both side)
v. Self Attested copy of all Mark Sheets, Certificate of qualifying examination for which
registration is sought. (2 copies both side)
vi. Registration Certificate and original NOC with covering letter of state if state have
paramedical council/Board for which registration is sought.
vii. Self Attested copy of Cast Certificate.(If applicable)
viii. Self Attested copy of Bona-fide Certificate.
ix. Self Attested copy of any Identification Card with photo issued by Govt.