TAMIL NADU DENTAL COUNCIL

(Arihant Majestic Towers, 5-0-3, # 216, J. N. Salai, Koyambedu, Chennai 600 107. Ph : 044 – 23638476)

Application form for obtaining a "Duplicate Registration Certificate"

(to be filled in by the candidate)

(FILL UP THE BELOW ALL DETAILS IN BLOCK LETTERS)

To
The Registrar
Tamil Nadu Dental Council, Affix recent
Chennai – 600 107. passport size
photograph
here
Sir,

I lost my BDS Regsitration Certificate bearing registration number ________________________

(mention the reason for lost) _____________________________________________________________

_____________________________________________________________________________________.

I humbly request you to provide me a duplicate registration certificate for the same. I will return this if the

lost certificate is found. The required particulars are given below :-

1) Name :

2) TNDC Regn. No. :

(enclose a copy of Registration certificate)

3) Date of Registration :

4) Permanent Residential Address :

(attach copy of address proof)

5) Mobile Number :

6) E-mail ID (Fill in Block letters) :

7) D.D. Details:
DD No. & Date :
Bank Name & Branch :

(The particulars given above are true with best of my knowledge)

Date : Signature
(Details overleaf) -2-
 (2)

Documents to be submitted by the applicant

along with the Application form

1. DD for Rs.500/- favouring Tamil Nadu Dental Council payable at Chennai.

(Cash & Cheque not accepted)

2. FIR Copy or Missing Certificate for misplaced of Original TNDC Registration

Certificate with their registration number and other details.

3. Affidavit from Notary Public (Advocate):-

(i)Misplacing of Original registration certificate

(ii)To issue duplicate certificate

(iii)To surrender Original certificate when it find afterwards

(iv)Affixed with recent passport size photo attested herewith.

4. Requisition letter from the candidate mentioning the above details.

5. Two recent Passport size photographs should be enclosed to the Application Form
(as similar in affidavit).
Do’s
His / her clear & clarity, plain background, straight face, official passport size
photo & within a week taken photographs only accepted.

Dont’s
His / her free hair, front hair, side face, selfie, scanned & old photo not accepted.

6. A copy of old registration certificate (if available).

7. A copy of Candidate photo identification proof in Tamil Nadu. (Aadhaar card, Voter
id, Driving Licence & Passport)

8. A self-addressed green cloth cover (10”x 12” size) with Rs. 50/- (within Chennai –
Rs.40/-) Postal stamps.

INSTRUCTIONS

a) If a Candidate cannot come personally he / she will submit his / her Form duly
signed and give separate authorization letter to someone or send by post.

b) All particulars of the application must be filled by the applicant only in neat
legible hand.

c) Dentist should write his / her name & Tamil Nadu Dental Council registration
number on the backside of the DD.