Schedule 1
(Relating to Sub-rule (1) of Rule 3)
Specimen of Signature
The Registrar,
Nepal Medical Council
Kathmandu, Nepal.

Dear Sir/Madam,
I hereby submit this application for having registered my name permanent/
temporary/trial/ specialist as per rule in the registration book of Nepal Medical
Council. I request you to register my name in the registration book of the Council
and issue a certificate thereof. I have enclosed herewith original certificates of all
academic degrees, mark sheets, citizenship and other certificates I have obtained and
certified copies thereof, three copies of recently taken passport size photographs and
banks voucher of NRs………. for application fee.
Applicants
Full name of Applicant: Signature………
Permanent address: Date:………
Temporary Address:……….
Father’s name: ……………
Grand Father’s name:……….
Place proposed for work…
Academic and other degrees obtained: (1)
(2)
(3)
(4)

Amended by Third Amendment

The institute awarding academic and other degrees:
Year of issuance: –
If applicant’s name is registered in other Vocational Council, name and address of
such Council:
Specimen of the applicant’s signature to be made in the prescription
Date:
Identity: (From Council’s member/Council’s registered medical practitioner)
I know the applicant medical practitioner ………… … … … … … well. His
statement is true; upon misrepresentation be done as per the law.
Certifier’s
Name: –
Signature: –
Registration No:
Address:
Date: –