Application for Registration, , ,

Under section 33 of Pharmacy Act (V[I of 1948)

TheRegistrar,RAJASTHAN PHARMACY COTINCILGovt. Dispensary Campus, SardarPatel Marg,JAIPUR=30200 l, Tel.lF ax : 0l 4l -2228600

Sir,I request that my name be entered in the REGISTER OF PHARMACISTS maintained by the RAJASTHAN

PHARMACYCOLTNCIL, undersection32ofthePharmacyAcll948 (VIII of 1948), andthaton such entryl maybefurnished with a certifi cate of registration.

I have given the particulars required on the reverse, and I declare that they are correct, and that I reside/carry onthe businessorprofession ofPharmacy inthe StateofRajasthan, myaddress beingas given below.

The Prescribed Application fee of .Rs. 1000/- one thousand only is paid herewith vide I.P.O./D.D./Banker

Council.Jaiour'

The undermentioned diplomas/certificates/documents are enclosed in original with one attested Photocopyand itis requestedthatthey be returnedto meonthe disposalofthe case.

' I.sbcoNpeRYSCHooLCERIIFICATE (tutarksheuisnotacceptable)2. SENIOR SECONDARY CEMIFICATE/ Mark Sheet

3.DEGREE/DIPLOMA/PROVISIONAL CritiJi*trituedbyUniversity/Boardasaproofofhavingpassedapproved examination ofPhannacy. (Provisional Certificate issued by college is not acceptable)

4. MARK SHEET ofDegree/Diploma Pharmacy.

5. PRACTICALTRAINING completiontorm in case otD.Phmma Candidates only.6. CERIIFICATE OF REGISTRATION as aPharmacist issued by other State Pharmacy Counc il (with two

attestedphotocopies)7 . ilfuo lotest possport siw PHOTO with name and datu prtnted on it one photo to be affaed on application

lorm.8. AFFIDAVIT in support ofdocuments and other details.9. Latest proofofresiding/carrying on profession or business ofpharmacy in Rajasthan. (Election Photo ID

Catd, Pasqnrt, Driving Licence, Ration Cord etc.)

Bonside resident urtlyiru, t no, admitted as a proof of resident10. I undertake to inform the Registrar, Rajasthan Pharmacy Council, my professional address immediately

aftertakingup employment (as aregisteredpharmacist/competentperson on any druglicence oranyother

To

Yours faithfully

FullName:.....................................

Note : Signature should be same as onpract. Training form & Midavit

Address:

PARTICULARS TO BE ruRNISHID BYTHEAPPTICANT

Name (in block letters)

Residential Address....

Qualification for registration (i) D.Pharma / B.Pharma

(ii) Registered Pharmacist with...... ..."...state Pharmacy Council.

[Year of Passing the D.Pharnra/B.Pharnra with the name of Board/

University or other examination body from which passedl

Employment, if any, Name of the Employer..

Note :It is futy of every Registered Pharmaxist to infonn the Registrar, Rajasthan Pharmacy Councilhis/hcr professional address immediately after taking up employnent (as a registered plwnnacistlCompetent person on any drug licence or any other employment and he/she should also lceep onintorming every change in his/her professional address/employnentlResidential Address.

(Applicant Signoture)

Full Name.

Address......

Dated."

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