Application form for registration U/S 19 of the RCI Act 1992

FORM-'A'

  Read the INSTRUCTIONS carefully before filling up the form.

(Note:- Please fill up the column carefully)       

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UTR/ TRN Number (NEFT Number) *
DATE *
BANK NAME *
 
Candidate's Name 
1.
Title *
First Name *
Middle Name
Last Name* >
Applicant's Father's / Husband's Name
2.
Title *
First Name *
Middle Name
Last Name*
3.
Correspondence  Address (Mentioning House/ Flat No., Street/Village Name/ Area/Tehsil/Ward Name/ Mobile No.)
(House/ Flat No, Street/ Village Name (Area/Tehsil/Ward Name/Mobile No) State*
District * Pin Code No* Rural/ Urban area*   
4.
Permanent Address     Same as Correspondence Address (Mentioning House/ Flat No., Street/Village Name/ Area/Tehsil/Ward Name/ Mobile No.)
(House/ Flat No, Street/ Village Name (Area/Tehsil/Ward Name/Mobile No) State*
District * Pin Code No* Rural/ Urban area*   
5.
Sex
Date of Birth   
Community Status *
6.
Highest Academic Qualification *           
    Year of Passing *     
7.

Registration
Applied for category
Code No.

Rehabilitation
Qualification / Programme  
Qualification Code

Institute / Study
Centre
Year of Passing

Language


8.
Working in the field of Rehabilitation for the Disabled Since (Year) [YYYY] [e.g.; 1985....]
9.
Total No. of years of experience in the field of Rehabilitation for the Disabled e.g.; 1,2,3,4.....
10.
Note:-Fill The Experience From Latest [currently Working] To Old Experience.
Name & Address of the Organisation
Period
From
To
Post Held
Salary Drawn




11.
Enter your Email-ID   Contact Number   
12.  Refrence of 3 Person's
Name Address Contact Details
1.
2.
3.

Note: Please enclose the relevant Documents duly Attested by a Gazetted officer in Support of your Academic /Professional Qualification and Service Experience in the field of Rehabilitation for the Disabled.

 

ATTACH YOUR CERTIFICATES:--    

  *Authentication Letter
  *10th/12th MarkSheet/Certificate(For Age Proof)
  *Final Rehabilitation Qualification Marksheet
  *Rehabilitation Qualification Certificate

Declaration by the applicant

I hereby declare that all the statements made in this application are true complete and correct to the best of my knowledge and belief. I understand that in the event of any information being found false or incorrect at any stage, my registration is liable to be cancelled.


Form of Declaration

(To be accepted by the applicant)

I, do solemnly affirm that I shall devote myself to the services and well being of the people of India and humanity, that to the best of my ability and knowledge I shall honestly, diligently, faithfully and without any fear, favour or ill-will discharge the duties of the profession upon which I am about to enter, that I shall uphold and maintain the honour end noble tradition of the profession, that the rehabilitation of the persons with disabilities shall be my best consideration and I shall maintain and respect the secrets and standards of professional conduct and etiquette and observe the code of ethics laid down in the Rehabilitation Council of India (Standard of Professional Conduct, Etiquette and Code of Ethics for Rehabilitation Professionals) Regulations, 1998.

I, make this declaration on this (YYYY-MM-DD) without any outside pressure and agree to abide by the same.                                                                                                                                                    


I accept the Terms & Conditions

Total Fee = Rs.1000/-