te of Assessment

Accepted? (YES/NO/ABSENT)

Name of the Assessor

Signature of Assessor

1.(a)

1.(b)

1.(c)

1.(d)

I 11 III IV

/DECLARATION FORM: 2014 - 2015 - FACUL TVName .. .Jij~....A.P.1?!1N.Kl.: y9..ft~..S.HVVft .Date of Birth & Age .I.~~.I.~ ....I..9.~..:t .Recent Passport size photo of the EmployeeSigned by Dean / Principal of the college.

~,L-Submit Photo ID proof issued by Govt. Authorities : ~l COllEGtPhoto ID submitted: V .P.Passport copy / PAN Card / Voter ID / Aadhar Card . A Wtf) _520 008

Numbe,A¥PA~2.l::,B. Issuedby9 ~YT:l9.t'1>!JA ~(Without Photo ID, Declaration form will be rejected and will not be considered as teachingfaculty)

1.(e) i.

1.(e)(i)a

1.(e)ii.

1.(e) iii.

1.(e)iv.

1.(e) v.

1.(f)

to

v

tf\

1~ .•. t

-1.(g) Have you undergone Training in "Basic Course Workshop" at MCI Regional Centre

in MET or in your college under Regional Centre observership?

Yes ~

If yes, give details.

Name of MC! Regional Centre where Date and place of trainingTraining was done/ If training was done in 1~'1'~ooi; J/fNlE1<-college, give the details of the observerfrom RC POND' C!H€MY;

1.(h) Copy of Passport IV oter Card / Electricity Bill /felephone Bill / Aadhar Card attached as aproof of residence.

1.(i) Contact Particulars: Tel (Office): (with STD code)

Tel (Residence): 0 B bb) 2-~4-2E2B~(with STD code)

E-mail address: _

1. G )

Mobile Number: '1 94=CJ---I-r------"~~b----l/'-----=-~-2--------L..--Date of joining present institution: A· 0~ .2....tJ ~ as --f~~~-'-'-''------

Joining report at the present institute attached. V1. G)a

2. Qualifications:

Qualification College University YearRegistrationNo.ofUG&PG with date

Name of the StateMedical Council

MBBS

11'1-13;I~ q. tqe!, ~'f' Nb~t~

~r:;UW{'~

MD/~

~(~)

Note: For PG-Post PG qualification additional Registration certificate particulars be furnished andsubject be indicated within brackets after scoring out whichever is not applicable.

Copy of Degree certificates of MBBS and PG degree attached. ~~

Copy of Registration of MBBS and PG degree attached. V-

2. (a)

2. (b)

2

r3 (a). Details of the previous appointments/teaching experience

Designation FromDD/MMfY\'

TotalExperiencein years &

months

Name ofInstitution

ToDD/MMfY\'

Department

Tutor/DemonstratorRegistrar/Senior Resident/Resident

AssistantProfessor

AssociateProfessor

Professor

Note:- Registrar/Senior Residents working in Anesthesia and Radio-diagnosis must have 3 yearsteaching experience in the respective departments in a recognized/permitted medicalinstitute as a Resident.

3(b). To be filled in by Ex Army Personnel only:

S.No. Place of Posting Designation PeriodFrom To

1.

2.

3.

4.

5.

3

4 .(a) __ "---:-'--=--L=-'--:-.,.-----:----j~ __ QI.

---1~.J...L~;Ld.L..f...f-+H~- after

4 .(b) I am not working in any other medical college/ dental college in the State or outside the Statein any capacity Regular / Contractual.

5. Number of Research publications in Journals during the last 3 (Three) academic years:

5. (a) International Journals:: ---=~--========__ _5. (b) National Journals:. _

5. (c) State/Other Journals: --- _

6. (a) My PAN Card No. is ----i1 <10 r A %b2l>£6. (b) I have drawn total emoluments from this college in the current financial year as under:-

Amount Received TDSJuly

August

September

October

November

December

January

February

March

April

May

June

4

REMARKS

S.No Documents Submitted1. Recent Passport size photo of the Employee, Signed by Dean / VYes / ~

Principal of the college. A ~

2. Photo ID proof issued by Govt. Authorities: Passport / PAN vYes / ~Card / Voter ID / Aadhar Card

3. Certified copies of present appointment order at present V"Yes / ~Institute. ~

4. Copy of Passport /Voter Card / Electricity Bill / Telephone Bill vYes / Ni-/ Aadhar Card attached as a proof of residence.

5. Joining report at the present institute. VYes / ~6. Copies of Degree certificates of MBBSand PG degree. vYes / We:7. Copies of Registration of MBBSand PG degree. \,./"Yes / Wg::---,8. Copy of experience certificate for all teaching appointments ~/\-No

held before joining present institute. ~9. Relieving order from the previous institution. V Yes / ~

10. PAN Card V Yes / 1ii9:-11. Form 16 (TDS certificate) for the last financial year. \,./'"Yes / ~12. Letter head (in case of teachers who are practicing) ~/"No

Sien~

.JJJ~Signe~~ .----'~;~~e Te~1::

Date: b~II'UJl Date: Cal 1\ \ ~-{J

Countersi

"rOfessor f:t H•••e.,.rtment 0 [iochem,*,

••••• rtha Medica' Cell••••••••. General H••••••--.- ",,-AlJ~ -111 •.

V.J u •.Signed & Verified by the Assessor:

NOTE:

1. The Declaration Form will not be accepted and the person will not be counted as teacher ifany of the above documents are not enclosed/ attached with the Declaration Form.

2. The person will not be counted as a teacher if the original of Photo ID proof, RegistrationCertificates / Degree certificates / PAN Card / State Medical Council ID (if issued) are notproduced for verification at the time of assessment.

3. All the teachers must submit the revised declaration form in this format only. (Anydeclaration form submitted in an old format will not be accepted and he will not be countedas a teacher.)

. .6