West Bengal Medical Council Page 1 of 3 Application for change of Surname

Received Rs. ______________ only through Debit /

Credit Card vide Money Receipt No._____________
of __________20___

Cashier
Photograph to be affixed
To here, duly signed by the
The Registrar candidate and should be
duly attested by
West Bengal Medical Council a Medical Practitioner or
IB 196, Sector III , Salt Lake, a Gazetted Officer
Kolkata – 700 106

Dear Sir,
Change of Surname

I am registered with the West Bengal Medical Council against No.____________ dated
_____________ and I had updated my records in the State Medical Register. I would like to change my

surname from ___________________ ( Maiden Surname ) to _________________________

( Changed Surname ) for reasons as stated in the enclosed declaration. The prescribed fee and

necessary documents are furnished herewith, together with original Updated Registration Certificate.
Yours faithfully,

1. __________________________________
2. __________________________________
Signature of the applicant in full at
1. with the Maiden Surname and at
Date : ______________ 2. with the Changed Surname.
Address : ______________________________________
______________________________________
‘Phone / Mobile No. ____________________________
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Procedure
1. Declaration Form to be filled in by the candidate, duly counter-signed by a practitioner
registered with this Council.
Documents required
2. For Female Applicant :
a) Original Marriage Registration Certificate or an affidavit duly sworn in before a 1st Class
Magistrate, together with a copy – for verification and return of the original.
b) Original Updated Registration Certificate of this Council – to be surrendered,
3. For Male Applicant :

a) Degree / Diploma in original with changed surname incorporated thereon by the University
and a copy thereof.
b) Insertion in a Daily Newspaper stating the fact and the reason for the proposed change
( Full page of the Newspaper, with the advertisement published therein, is to be submitted ).
c) An affidavit, duly sworn in, before a 1st Class Magistrate and a copy thereof.
d) Original Updated Registration Certificate of this Council – to be surrendered.
4. Prescribed fee of Rs. 1000..00 ( Rupee one thousand ) only.

5. 2 copies of recent photograph [ size 35 mm x 25mm ] be furnished along with the

application, of which 1 be affixed on the application and should be duly attested by any
Gazetted Officer or by any practitioner registered with this council with full signature and
Registration Number, for verification. Balance one copy of photograph be submitted without
any attestation.
Continued on reverse
West Bengal Medical Council Page 2 of 3 Application for change of Surname

I, Dr. _____________________________________ ( Name with changed surname ) do hereby

declare that I am the same person by name Dr. ______________________________________________
who passed the LMF/MBBS Examination of the University of ___________________________________
State Medical Faculty of West Bengal in the year___________ and obtained the LMF / MBBS /
Diploma / Degree from that body, and the Registration Certificate No. ______________ from the
West Bengal Medical Council and that I desire to change by Surname to __________________ for the
following reasons:
____________________________________________________________

____________________________________________________________

I also declare that my :

A) Father’s Name is : _______________________________________

B) Husband’s Name is : _______________________________________

1. ________________________________
2. ________________________________
Signature of the applicant in full at
1. with the Maiden Surname and at
2. with the Changed Surname.
Date : Registration No.__________________

Address : ______________________________________
______________________________________
‘Phone/Mobile No. _____________________________

…………………………………………………………………………………………………………………….

This is to certify that the above declaration has been made by the Declarant Dr…………….
…………………………………. in my presence. To the best of my knowledge, he / she is the same
person who passed the ___________ Examination of the University of ______________ / State
Medical Faculty of West Bengal in ____________ and was registered with the West Bengal
Medical Council under No._______________.

____________________________________
Signature of the practitioner ( in full )
registered with the WBMC
Date : Registration Number __________________.

Address : ______________________________________
______________________________________
‘Phone/Mobile No. _____________________________

Continued to Page 3 for Office Use only

West Bengal Medical Council Page 3 of 3 Application for change of Surname

For Office use only

1.This is an application from ( 1 ) Dr. ____________________________________________, MBBS
/
_____________ ( __________________ U ) ____________ & Regn No. ______________ of
_______________ for change of her surname from “___________________________” to
“Mrs._________________________” in the office records due to ______________ ( state the
reason for change ), which had duly been certified by ( 2 ) Dr.
_____________________________________________, MBBS / _________________
( ________________ U ) ___________ & Registration No. ______________ of ___________________ .

2. The applicant had submitted copy of Affidavit / Marriage Registration Certificate

( enclosed ) in support of his / her application, which has duly been verified with
the Original / Certified copy of the same dated _________________.
1. Report against Registration No. _____________ of ______________

Name of Dr. ______________________________ having MBBS ( _________________ U )

_________ of __________________________________________________________________
__________________________________________________ is still borne in our Register.
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2. Report against Registration No. _____________ of ______________

Name of Dr. ______________________________ having MBBS ( _________________ U )

_________ of __________________________________________________________________
__________________________________________________ is still borne in our Register.

3. Declaration submitted by the applicant has been checked. Names of both the
signatories thereon are still borne and their signatures seem to be genuine.
4. The said changes may be incorporated in our records and a fresh Updated
Registration Certificate may be issued with the said change.
For order.
______________________ May be changed
Signature of the Dealing Assistant

Registrar, West Bengal Medical Council

………………………………………………………………………………………………………………………….

Received
1. Original Updated Registration Certificate ( Registration No. _____________ ) of
Dr. _________________________________________ with changed surname incorporated
therein, by self.
2. Original Updated Registration Certificate ( Registration No. _____________ ) of
Dr. _________________________________________ with changed surname incorporated
therein, on his / her behalf on production of letter of authority.

( Strike out whichever is not necessary )

----------------------------------
Date : Signature of the receiver in full

Proforma amended in terms of the decision taken in the meeting of the Executive Committee on 13-04-2004,
duly ratified by the Council at its meeting held on 27-04-2004