Fees shall be levied by the Council as shown below:
Sr. No. Purpose Rs.
(i) For recording change of name in the register. 50 For entering each additional qualification specified in the Schedule to the Act
(ii) or in the First Schedule or Part I of the Third Schedule to the Indian Medical 50 Council Act, 1956.
(iii) For entering each additional qualification specified in the Second Schedule or 50 Part II of the Third Schedule to the Indian Medical Council Act, 1956.
(iv) For issue of duplicate certificate of registration. 100
(v) For issue of a certified copy of an entry in the register. 50
(vi) Provisional Registration. 200
(vii) Permanent Registration. 500
(viii) Temporary Registration (special). 250
(ix) Continuation (Renewal) of Registration. 50 _______ FORM 1 (See Rule 4) Notice of publication of Electoral Rolls
1. Notice is hereby given that the electoral roll for election of members of the Goa Medical Council has been prepared in accordance with the Goa Medical Council Rules, 1995 and copies of the roll will be available for Inspection and/or sale at the office of the Council at the address of the Council.
2. (a) Every claim for inclusion of a name in the roll; or
(b) Every objection to—
(i) the inclusion of any other person’s name in the roll; or
(ii) to any particulars in any entry in the roll;
shall be addressed to the Registrar and shall be presented or sent by post to him at the address referred to above so as to reach him on or before the ….. day of …. 19… ……………………… Registrar, Goa Medical Council.
Panaji Dated the ….. day of ….. 199 ….
________ FORM 2 (See Rule 7) Notice of Election Election to the Goa Medical Council, Panaji Notice is hereby given pursuant to the provisions of the Goa Medical Council Rules, 1995 that ……….
(1) an election is to be held of *…………… members of the Goa Medical Council elected by the registered practitioners from amongst themselves;
(2) nomination of registered practitioners eligible to fill the seat/seats @ are invited;
(3) forms of nomination paper may be obtained from the Registrar on application;
(4) nomination papers may be sent so as to reach the undersigned at or before…….……..on (hours) the …………… …..…….;
(date) (place)
(5) nomination papers will be taken up for scrutiny at ………… On the …............ at ……..;
(hours) (date) (place) (5-A) candidature may be withdrawn by a notice in writing signed by the candidate and delivered to the Returning Officer so as to reach him at or before ……………………….
(hours) …………………………………………………;
(date) (place)
(6) in the event of the election being contested …………
(a) the voting papers may be sent by the electors so as to reach the Returning Officer at or before …………. on the …………. At …………..
(hours) (date) (Place)
(b) the votes will be taken up for scrutiny and counting at …………. On the…………at (hours) (date) ………………;
(place) Date: ……….
…………………………..
Address: ……………. Returning Officer.
* Here insert the number of impending vacancies.
* @Strike off the alternative not required.
______________ FORM 3 (See Rule 8) Form of Nomination Paper Election to the Goa Medical Council, Panaji (To be filled in by the candidate) I hereby offer my candidature for the election to Goa Medical Council. I further declare that I shall work for Goa Medical Council if elected.
Date …………………… ………………………… (Signature of candidate) (To be filled in by the Proposer) I hereby nominate ………………………… as a candidate for the forthcoming election to the Goa Medical Council.
(1) Full name of candidate …………………………………………………………………
(2) Full postal address of the candidate ……………………………………………………….
(3) Serial number of candidate in the electoral roll …………………………………………
(4) Full name of proposer ……………………………………………………………………..
(5) Full postal address of proposer …………………………………………………………
(6) Serial number of proposer in the electoral roll …………………………………………..
Date …………………… Signature of Proposer (To be filled in by the Seconder) I second the above nomination-
(1) Full name of seconder …………………………………………………………………….
(2) Full postal address of seconder ………………………………………………………….
(3) Serial number of seconder in the electoral roll ………………………………………….
Date ………………….
Signature of Seconder (To be filled in by the Returning Officer) Serial No. of nomination paper ……………………… This nomination paper was delivered to me at my office …….. (hour) on ……………… (date).
Date ……………….
……………………………… Returning Officer Decision of Returning Officer accepting or rejecting the Nomination Paper.
I have examined this nomination paper in accordance with the provisions of the Goa Medical Council Rules, 1995, and decided as follows:
— Date …………………… …………………………….
Returning Officer _______ FORM 4 (See Rule 16) Goa Medical Council Counterfoil of Ballot Paper Ballot Paper Outerfoil (front)
(1) Serial number of ballot paper ………. Serial No. Name of Candidate Vote (X)
(1)
(2) (3)
(2) Number of elector on the electoral roll to whom the ballot paper has been sent.
………………….
(Returning Officer) (Back of outerfoil) DIRECTIONS TO ELECTOR FOR RECORDING OF VOTES
(1) You have …….. vote(s).
(2) Record each vote by putting a cross in column (3) against the name of the candidate for whom you wish to vote.
(3) You must not put more than *……………… crosses.
(4) You must not put more than one cross opposite the name of any candidate.
(5) Your vote is secret. You must not put your signature on the ballot paper or make any other mark on it which will reveal your identity.
(6) After you record your votes put the ballot paper in the smaller cover, close the cover and put it in the larger cover. Close the larger cover. Write your name and put your signature at the places marked on the larger cover.
(7) Despatch the larger cover to the Returning Officer so as to reach him before @…….
*The particulars shall be filled in by the Returning Officer.
@ Here enter the time and the date at or before which the ballot paper must reach the Returning Officer.
FORM 5 (See Rule 17) Large Cover Election to the Goa Medical Council, Panaji ELECTION—IMMEDIATE No. of elector in the electoral roll:— To The Returning Officer Address:
Name of the elector Not to be opened before counting ………………………..
Signature of the elector ………………………….
________ R eg is tr at io n N um be r
(1) FORM 6 (See Rule 53) Form of Register of Medical Practitioners
PART Full name including A dd re ss Na tio na lit y Qualifications D at eo fR eg ist ra tio n Da teo fre mo va lan dif su bs eq ue ntl yre ins tat ed Re -re gis ter ed the da teof reen try aft err em ov al Re m ar ks su ch as wa rn ing sm er itc er tif ica te, aw ar ds ,et c.
father’s/husband’s name and date on and surname and also which each maiden name and surname was obtained in case of a married woman
(2) (3) (4) (5) (6) (7) (8) FORM 7 (See Rule 61) Form of Individual Notice for Renewal of Registration To (Here mention the name and last known address of the Medical Practitioner).
Sir, In pursuance of clause (b) of Section 23 of the Goa Medical Council Act, 1991, notice is hereby given that you should pay to the undersigned a fee of ….. rupees in cash or by crossed postal order or by money order or by Demand Draft payable in Panaji on or before *… for the continuance of your name on the register under the said Act for a further period of five years.
If you fail to pay the fee within the time stated above, your name shall be removed from the register as a defaulter.
Your faithfully, …………………………….
Registrar, Goa Medical Council Date:
Address:
*Here enter the date two months subsequent to the date of publication of general Notice in the Goa Official Gazette.
FORM 8 (See Rule 57) Certificate of Registration GOA MEDICAL COUNCIL, PANAJI Registration No. ………………… This is to certify that the withinsigned …………..
Space for Photograph Doctor/Shri/Shrimati/Kumari* …………………………………………………………………...
(Full name) possessing the qualifications of ………….. has been duly registered under the Goa Medical Council Act, 1991, in part **………………… of the register.
In witness whereof are herewith affixed the seal of the Goa Medical Council, Panaji, and the signature of the Registrar.
…………………… Registrar, Goa Medical Council.
Dated the ……………… 19 SEAL OF THE COUNCIL *Strike off the alternative not applicable.
**here insert the part of the register.
FORM 9 (See Rule 59) GOA MEDICAL COUNCIL, Certificate of Provisional Registration Registration No. ………………… This is to certify that *Shri/Shrimati/Kumari ……………………………………… of …………..having passed the Third M.B.B.S. Examination of the …………. University in the year … has been given provisional registration under the Goa Medical Council Act, 1991, for the purpose of Practical Training (Internship). This certificate does not entitle the holder to practise medical profession at any place other than the medical college, hospital or its ancillary units.
In witness whereof are herewith affixed the seal of the Goa Medical Council, Panaji, and the signature of the Registrar.
Subject to the provisions of the said Act, this certificate is valid upto the day of ** …..19 completion of Internship whichever is latest.
or SEAL Dated the ……. 19 ……………… Registrar.
N. B.:— This certificate must be returned to the Council at the time of permanent Registration.
* Strike off the alternative not required * Here insert the date of validity of certificate.
FORM 10 (See Rule 55) Form of Application for Renewal of Registration To, The Registrar, Goa Medical Council *…………………………….
……………………………..
Subject: Renewal of Registration.
Sir, In reply to your notice dated ….. I request that my name may be continued on the Register of Medical Practitioners for a further period of five years. The necessary particulars are given below:
— Full name: ……………………………….………… (Beginning with surname) Maiden name in case of married woman ………………………………………………….………… (Beginning with surname) Registered qualifications with dates of Registration ………………………………………………...
Registration No. ……………………….
Permanent address for purpose of registration ……………………………………………………… Yours faithfully, (Signature) Date ……………… NOTE
1. This form shall be returned duly completed so as to reach the Registrar, Goa Medical Council for continuance of registration within forty-five days of the date of the notice.
2. All details shall be correctly filled in.
3. Applications which do not contain the required particulars are liable to be rejected.
4. Additional qualifications and change of address for communication must be notified to the Council immediately.
*Here enter full address of the Registrar.
FORM 11 (See Rule 67) NOTICE
(1) On behalf of the Goa medical Council, I ……………..... the Registrar, hereby give you (name) notice that on an examination of the materials available, it is found that prima facie case exists for holding an inquiry into your conduct in the matters hereafter mentioned and do hereby charge you ….. as under:— (Here mention specific charges)
(2) A statement of allegations and a statement of evidence are appended.
(3) You are called upon to put in your written statement of defence alongwith such documents as you intend to reply on in your defence in answer to the above charges within…… days from the date hereof and to state at the same time whether you desire to be heard in person by the Council. If you desire to examine any witnesses in your defence, you are called upon to furnish at the same time the names and addresses of your witnesses. On your failure to put in your statement or to furnish the names and addresses of your witnesses within the time allowed to you, it will be presumed that you do not wish to make a statement or to furnish any witnesses.
(4) You are further called upon to state why the above charges or any of them if held proved, should not be considered as good and sufficient ground for imposing upon you any of the penalties specified in sub-section (1) of Section 22 of the Goa Medical Council Act, 1991.
(5) A copy of Section 22 of the Goa Medical Council Act, 1991 together with extract of rules relating to inquiry procedure under the Goa Medical Council Rules, 1995 is enclosed for your ready reference. Your attention is particularly invited to Rule 67. You may, if you so desire, apply for copies of the relevant documents.
Date ………….
………….
Registrar, Goa Medical Council.
FORM 12 (See Rule 75) Application for Re-entering name in the Registrar To, The Registrar, Goa Medical Council.
(1) I, the undersigned (i) ….. now holding the qualification (ii) ….. apply for re-entry of my name in the Register.
(2) By the order dated (iii) ….. the Goa Medical Council, directed my name to be removed from the Register on a complaint made by (iv) …. and the misconduct for which the Council directed the removal of my name was (v) ….
(3) Since the removal of my name from the Register, I have been residing at (vi) … and my occupation has been (vii)… .
(4) It is my intention if my name is re-entered in the Register to (vii) … .
(5) The grounds of application are (vii) … .
(6) I forward herewith …. .
(a) The degree/diploma/licence of (ii) … in original.
(b) A certificate of good character from (ix) …. .
………………………………………..
Signature of the Registered Practitioner
(i) Insert full name.
(ii) Insert qualifications, if any.
(iii) Insert date.
(iv) Insert name and address of complainant, if any.
(v) Insert charge on which name was removed.
(vi) These blanks must be filled in according to circumstances.
(vii) Insert particulars as to proposed future professional occupation.
(viii) All facts and grounds on which the application is made should be clearly and concisely stated.
(ix) Insert name of Gazetted Officer or Justice of Peace giving the certificate.
________ FORM 13 (See Rule 96) Form of List of Registered Practitioners
PART Serial No.
Name, qualifications and Registration No. and date of address registration
(1) (2) (3) FORM 14 (See Rule 59) GOA MEDICAL COUNCIL Form of Application for Provisional Registration under Section 19 To The Registrar, Goa Medical Council, Panaji.
Sir, I request you to give me provisional registration under section 25 of the Indian Medical Council Act, 1956 and to issue the necessary certificate. My particulars are stated below:
Name in full (beginning with surname …………………………………………………………........
and including *father’s/husband’s ………………………………………………………………..
Name in (BLOCK LETTERS ONLY) …………………………………………………………...
Address ...…………………………………………………………… ……………………………………………………………… ……………………………………………………………… Maiden name and surname in the …………………………………………………………………… case of a married woman (beginning ……………………………………………………………..
with surname in BLOCK LETTERS). …………………………………………………………… Nationality : ………………………………… Date of Birth: ……………………………..
Qualification or Examination passed ………………………………………………………………...
Name of University or Licensing Body ……………………………………………………………...
Institution from which appeared for ……………………………………………………………… the Examination and number at ………………………………………………………………….
the Exam.
Date of passing the Examination or of ……………………………………………………………....
obtaining the qualification.
I forward herewith:
(i) My Birth Certificate or Matriculation Certificate or SSC Exam. Certificate or School Leaving Certificate or Domicile, Age and Nationality Certificate or extract from Passport in original.
(ii) The Degree or Diploma or Certificate of passing the qualifying Examination which I possess, in original, and
(iii) Certificate from the Head of the Medical Institute (recognised by the University) where I have been admitted for internship training.
These may be returned to me when no longer required.
Please forward Original Certificates alongwith copies thereof duly attested by a Gazetted Officer. The Originals will not be returned if they are not accompanied by copies.
200/- Receipt No. ......................
Date ....................
I have been selected for *Practical .....................................................................................................
training at the (State name of approved Institution) Employment in a medical capacity at the …………………………………………………………… *Appointment in the Medical ...................................................................................
(State name of approved Institution) Services of the Armed Forces ...................................................................
of the Union and I enclose as evidence. ...................................................................
(4) The registration fee of Rs. 200/- (Two hundred only) is sent by Demand Draft.
(5) I am applying for registration for the first time and I was not registered as medical practitioner in India before the date of this application.
(6) I have carefully read the instructions sent with this form and I certify that the particulars furnished above are true to the best of my knowledge and belief.
Yours faithfully, ..............................
(Usaual Signature) Date: .....................................
Place: ......................................
INSTRUCTIONS
(1) All particulars shall be filled in by the applicant only.
(2) All particulars should be in neat legible or type-written.
(3) The registration fee should be sent by Demand Draft only.
(4) The applicants should remember that their names entered in the application must exactly correspond with their names at the University or other Examinations as the case may be.
(5) Evidence under paragraph 3 of the application shall include selection or appointment Order.
Hours of Payment:
From 9.30 a.m. to 1.00p.m. and from 2.30 p.m. to 5.00 p.m. on all working days from Monday to Friday.
Provisional Registration fee .................................. Rs. 200/- ________________________ FORM 15 (See Rule 59) GOA MEDICAL COUNCIL Form of Application for Registration To The Registrar, Goa Medical Council, Panaji.
Sir, I request you to register my name and other particulars as stated below, under the Goa Medical Council Act, 1991 and further to give me a certificate of registration:— NAME IN FULL (beginning with …………………………………………...................
surname and including *father’s/ ……………………………………………...............
/husband’s name in BLOCK LETTERS) …………………………………………...................
ADDRESS (to be entered in the ...…………………………………………………...
Register) ……………………………………………………...
………………………………………………….......
Maiden name and surname in the ……………………………………………………..
case of a married woman (beginning ……………………………………………………...
with surname in BLOCK LETTERS). ……………………………………………………...
Nationality : …………………… Date of Birth: ……………………………................
Description of qualifications of which registration is desired. The name of the University or The Licensing Body should Also be stated.
Date of obtaining the qualifications.
State also the institution from which you appeared for the said exam.
alongwith your number at examination.
(1) Date ............................................
(2) Institution: .................................
....................................................
(3) No. at the Exam. ........................
I forward herewith original certificates alongwith their xerox copies:—
(1) *Birth Certificate or *Matriculation Certificate or *SSC Exam. Certificate or *School Leaving Certificate. *The degree *Diplomas *Licence *Certificates *Other evidence in support of my having obtained the qualification which I possess, in original.
*2 Passport size photographs.
*Evidence of Registration in the Dte. of Health Services, Panaji, Goa. *File.
(2) The registration fee of Rs. 500/- (Rupees five hundred only) is sent by Demand Draft in favour of the Registrar, Goa Medical Council, Panaji-Goa.
(*3) I am applying for registration for the first time and I was not registered as a medical practitioner under any law in India before this.
(*4) I am/was provisionally registered under Section 25 of the Indian Medical Council Act, 1956 and enclose the certificate of provisional registration in original.
(5) I was/have been registered under the .......... (See the Act or Law) in the year ................
and my registration number is/was ....................
(6) I have carefully read the instructions sent with this form and I certify that the particulars furnished above are true to the best of my knowledge and belief.
Yours faithfully, …………………….
(Usual Signature) INSTRUCTIONS
(1) All particulars in the application shall be filled by the applicant only.
(2) (2) All particulars should be in neat legible hand.
(3) The registration fee should be sent by Demand Draft only.
(4) The applicants should remember that names entered in the application must exactly correspond with their names at the University of other examination, as the case may be.
Specimen of Practitioner’s Signature as used on Medical Certificate Present Address *Strike off the alternative not applicable.
N.B. Please also forward copies of certificates and other evidence, if any, under para 2 of the application.
Hours of Payment:
9.30 a.m. to 1p.m. & 2 p.m. to 5p.m. on all working days from Monday to Friday.
Registration fee—Rs. 500/-.
Demand Draft in favour of the Registrar, Goa Medical Council, Panaji, Payable in Panaji.
__________________ FORM 16 (See Rule 61) Form of final notice to a registered practitioner for continuance of his name on the Register To, (Here mention the name and address of the Medical Practitioner as entered in the Register) Sir, I am directed to invite your attention to my notice dated the ....... 19 ......., and to give you a final notice as required by Clause (b) of Section 23 of the Goa Medical Council Act, 1991, calling upon you, to return to me the enclosed form of application for the continuance of your name in the Register within forty-five days from the date of this notice together with a fee of Rupees fifty only.
If you fail to return the form of application duly filled in and signed alongwith the fee of rupees fifty on or before ......... your name will be removed from the register as a defaulter.
Yours faithfully, Registrar, Goa Medical Council.
*.............................................
Date ...............................................
*Here enter full address of the Registrar.
_________ FORM 17 Form of Notice to a Registered Practitioner for continuance of his name on the Register, under Clause (b) of sub-section (4) Section 16 (Here mention the name and address of the medical practitioner as entered in the register).
(1) In pursuance of Clause (b) of sub-section (4) of Section 16 of the Goa Medical Council Act, 1991 notice is hereby given calling upon you to return to me the enclosed form of application for the continuance of your name on the register within forty-five days of this notice.
(2) If you fail to return the application duly filled in and signed on or before ................. it shall not be accepted thereafter unless it is accompanied by a late fee of rupees fifty only.
Registrar, Goa Medical Council.
*.................................................
...................................................
Date ..........
*Here enter full address of the Registrar.
By order and in the name of the Governor of Goa.
E.A.Cardozo, Under Secretary (Health).
Panaji, 9th January, 1996.
(Published in the Official Gazette, Series I No. 14 dated 4-7-1996-Supplement).