Schedule-1
(Relating to Sub-rule (1) of Rule 5)
Application form for name registration

The Nepal Health Professional Council,
Kathmandu.
I, hereby, make this application setting out the following details to get may name
registered in the register of the Nepal Health Professional Council, pursuant to
Section 16 of the Nepal Health Professional Council Act, 2053 (1997) and as per
Rule 5 of the Nepal Health Professional Council Rules, 2056 (1999).
1. Full name and surname:
2. Name (in block letters):
3. Date of birth:
4. Father’s name:
5. Grand-father’s name:
6. Name of husband or wife, if married:
7. Permanent address:
Zone: District: VDC/Municipality:
Ward No. Tole: Village:

Temporary address:
Zone: District: VDC/Municipality:
Ward No. Tole: Village:
8. Address for correspondences:
9. Name of health institution, if any, being engaged in:
Address:
10. Subject and level intended to be registered in presently:
11. If the name was registered in any professional council heretofore:
Name of the Council:
Registration number: Date: Subject: Level:
12. Details of educational qualification or degree:
(a) General:

(b) Vocational/professional:

The contents mentioned above are true and correct, if proved false, I shall
bear and pay according to law.
Applicant’s:
Signature:
Full name, surname:
Date:
Note: The applicant has to submit three passport size photographs, citizenship
certificate and originals of the educational qualification or degree pr training
as mentioned in the application form and two certified duplicate copies
thereof, along with the application.